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RD546 M95 Operative surgery of
RECAP
Murphy
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Operative surgery of the gall tracts.
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OPERATIVE SURGERY OF THE GALL
TRACTS,
With Original Report oi' Twkntv Succios^kiji. Ciiomccystkntfr-
OSTOMIES BY MeANS Ol' THE AnASTOMUSIS Jiu-|"IOi\.
JOHN B. MURPHY, M. D., Chicago, III.
I^KOFESSOK OF SURCxERY, COLLEGE OF PHYSICIANS AND SURGEONS ; PROFESSOR OF SURfrEKY,
POST-GKAUUATE MEDICAL SCHOOL AND HOSPITAL ; ATTENDING SURGEON COOK COUNTY
HOSPITAL ; ATTENDING SURGEON ALEXIAN BROTHERS HOSPITAL :
VICE PRESIDENT OP NATIONAL ASSOCIATION OF
RAILWAY SURGEONS, ETC.
A\-i7i/ /'c'/orc' the Section on Siirp;<;ry and Anatomy at the Forly-fourt]i Annual Mectii
of the Ainen'ean Medical . Issociation .
Kepri)iled from The Chicago Medical Recorder, March, iSq4.
PRESS OF
The McGluer Printing Company
63 dearborn st., chicago.
OPERATIVE SURGERY OF THE GALL TRACTS,
With Original Report of Twenty Successful Cholecystenter-
OSTOMIES BY MeANS OF THE ANASTOMOSIS BUTTON.
By JOHN B. MURPHY, M. D., Chicago, III.
PHOFESSOR OF SURGERY, COLLEGrE OF PHYSICIANS AMD SURGEONS; PROFESSOR OF SURGERY j,
POST-GRADUATE MEDICAL SCHOOL AND HOSPITAL; ATTENDING SURGEON COOK COUNTY
HOSPITAL; ATTENDING SURGEON ALEXIAN BROTHERS HOSPITAL;
VICE PRESIDENT OF NATIONAL ASSOCIATION OF
RAILWAY SURGEONS, ETC.
Of the many absorbing topics of medical literature, of the
many changes in the art of surgical treatment made in the last two
decades, of the many glorious achievements attained in this period
under aseptic and antiseptic methods, of the many of these iri
which the results are still imperfect and offer great reward for hon-
est experimental and clinical research, one of the youngest and yet
a very interesting and inviting one is the surgery of the gall tracts.
All of its achievements are the fruit of very little over a decade of
labor, and probably we have only just begun to make progress in this
direction; great possibilities are before us. In drawing your atten-
tion to this subject to-day, it is not my desire so much to enumer-
ate the steps already accomplished, as it is to ask your assistance
for its further advancement. The scope of this paper includes
only the operative element of the surger}'- of the gall tracts; I will
therefore not go into details as to the lesions which produce the
necessity for the operation, but will only refer to them cursorily, as
indications for the special operations to be performed. We will
First devote a few minutes to the surgical anatomy of the region
Read before the Section on Surgery and Anatomy at the Forty-fourth An-
nual Meeting of the American Medical Association.
in which they are situated, as well as to the tracts themselves.
Second, we will consider the functions or physiology of the gall
bladder and gall tracts; for good surgery is based on good physi-
ological principles, and good operations must be executed on good
anatomical lines. Third, we will take up the individual operations,
and the special indications for each.
THE GALL BLADDER.
The fundus of this organ lies opposite the ninth costal cartil-
-age, close to the outer edge of the rectus, the body itself is situated
in a fossa on the under surface of the right lobe of the liver, having
the quadrate lobe to its left. It is in immediate contact with the
hepatic flexure of the colon, and the first portion of the duodenum.
The gall bladder is of pyriform outline, and when full is seen pro-
jecting beyond the anterior border of the liver, coming in contact
with the abdominal wall at the cartilage of the ninth rib. It ex-
tends almost directly backward, deviating only a little to the right
and upward; it measures from two and one-half to four inches in
length, and one and one-half inches in diameter at the widest part,
and holds about one fluidounce. It is always found full, except where
some external pressure is brought to bear upon it. It is attached to
the liver by connective tissue, the lower surface is covered by
peritoneum, though occasionally it entirely surrounds the viscus
and forms a sort of mesentery to attach it to the liver. The neck
of the gall bladder gradually contracts until it forms the cystic
duct. This duct is a tube an inch to an inch and a half long,
which connects the neck of the gall bladder with the hepatic duct,
and combines to form the common duct, or the ductus communis
choledochus. The cystic duct is directed backward and to the
left as it runs in the lesser omentum; the hepatic artery being to
the left and the portal vein behind. The hepatic artery passes
behind the hepatic duct and between it and the portal vein. This
is a very important point to remember, as it assists the operator
in differentiating between the duct and the vein in operations.
The duct and the vein having the same color, and being situated
in close proximity, it is very important to recogize the duct in this
situation above the artery, and the vein below it. The hepatic
duct is formed by a branch from each lobe of the liver in the trans-
verse fissure, and is directed downward and to the rilght in the les-
ser omentum, the hepatic artery being to the left at its first part,
and then behind. It is not quite two inches long and joins with
t"he cystic duct to form the common duct. The common bile duct
is about three inches in length, it passes down between the layers
of the lesser omentum, immediately in front of the portal vein, and
to the right of the hepatic artery; it then passes behind the first
part of the duodenum, then between the second part and the head
of the pancreas and ends at the lower part of the second segment
of the deodenum by opening into that part of the intestine on its
left side and somewhat behind. It pierces the intestinal wall
very obliquely, running between the muscular layers for about
three-quarters of an inch. The pancreatic duct enters the common
duct just before its termination. Immediately below where the
pancreatic duct opens into the common duct, there is a dilatation
of the common tube, called the ampulla of Vater. There is a slight
constriction at the terminus of the duct, the papilla. This papilla
in the duodenum is about four inches from the pylorus. The com-
mon duct has a diameter of two lines, its width at the ampulla is
three lines, it is narrowest at its outlet into the duodenum. The
cystic and hepatic ducts are a little narrower than the common
duct. The diameter of the ducts is a matter of considerable prac-
tical importance; that of the cysticus and choledochus being so
near alike, that a concrement that will produce obstruction in the
former will do the same in the latter, though of a lesser degree un-
til it reaches the ampulla, where there is considerable more space.
Stones are frequently retained in the ampulla, as the orifice of the
duct in the intestine is much smaller than any portion of the tract.
Calculi retained in this position buried behind the duodenum pro-
duce very grave symptoms, as jaundice, and a septic fever of a
typical intermittent character.^
Obstruction at this point, on account of its location, is so very
difficult to reach and remove that the surgeon, in place of attack-
ing the obstacle producing the obstruction, selects a method of
circumventing it and allows the bile to enter the duodeum through
another tract, viz., by cholecystenterostomy. It will be seen that
the distance from the fundus, of the gall bladder to the opening of
the duct in the duodenum is made up of the combined lengths of
the gall bladder, ductus cysticus and choledochus, measuring in
all from six and a half to eight and a half inches. This should be
remembered in sounding the ducts for obstructions with a bougie
or probe. The gall bladder consists of three coats, the serous, the
fibrous and muscular, and mucous. The serous coat covers only
about two-fifths of the surface, that on its under side. The mu-
' See Dr. W. E. Quine's excellent monograph on this subject.
cous is raised in rugae, bounding polygonal spaces, which are
largest about the body. These rugae play an important part in the
formation of hepatic calculi. The mucous membrane is lined with
columnar epithelium, and contains many mucous glands. At the
neck the mucous membrane forms folds projecting into the interi-
or acting as valves, Heister's. This layer contains an anastomosis
of blood vessels and a fine plexus of lymphatics; the presence of
these lymphatics accounts for the formation of secondary abscesses
and septic manifestations from infective lesions of the gall bladder.
The fibrous and muscular coat consists more of fibrous than mus-
cular tissue and has but very little power of contraction, since I
found in the healthy gall bladder of the dog, by ligating the ductus
cysticus, that only a small quantity of bile, average thirty drops,
was forced out by the automatic contraction of the gall bladder
through a canula placed in its wall; this quantity representing
only about six per cent of the contents of the gall bladder.
PHYSIOLOGY.
This leads us to a consideration of the physiology of the gall
bladder. The gall bladder is credited by physiologists with being
the store house for the bile. Landois states that "the gall is
secreted continually, but part is stored in the gall bladder, and
poured out copiously during digestion." This expresses the ac-
cepted theory of the functions of the gall bladder. I desire to
question the correctness of this theory, and in order to place the is-
sue more clearly before you, I make the assertions, bold as the}'
may seem, first, that the gall bladder is not for the purpose of storing
the bile and delivering it into the intestines on demand; second,
that the gall bladder is the controller or governor of the tension of
the bile circulation. When we consider that the amount of bile
secreted daily is forty ounces, Murchison; 566 grams, Westphalen;
or 652 cubic centimeters, John Ranke; or about 105 minims to
each pound of body weight, we can readily see what little differ-
ence it would make in the quantity and current of bile entering the
intestines at the time of digestion, even if the gall bladder should
contract and empty its whole contents, one ounce, into the intes-
tine during the period of two hours of time, /. e, the two hours be-
tween three and five hours after the ingestion of a meal. For in-
stance, the bile flows most rapidly at two periods viz., between
three and five hours and between eleven and thirteen hours after
the ingestion of food; in those two periods about ten ounces of bile
is discharged. If the quantity of bile forced out of the gall blad-
der by its inherent contraction, one-half drachm, be added or
taken from these ten ounces, would it make any perceptible differ-
ence in the current? It can be readily seen that it would make no
appreciable difference in the whole quantity discharged, i. e., ten
ounces. We are then forced to the conclusion that the liver se-
cretes at these periods this large quantity and that it is not
"poured out" by the gall bladder as stated by Landois. Again, if
the function of the gallbladder were to contract and expel its con-
tents during the act of digestion, would we not frequently find an
empty and physiologically contracted gall bladder either ante-mor-
tem or post-mortem ? I have yet to find one, notwithstanding I have
observed them on the living and dead subjects, at all hours before
and after eating and I have yet to see a surgeon who has found a
physiologically empty gall bladder. That the gall bladder does not
empty and fill with each digestive act is further supported by the
fact that the bile in the healthy gall bladder is of much greater
specific gravity than that in the hepatic, cystic and common ducts
of the same subject. The bile in the cystic duct is like the bile in
the hepatic and common ducts, and differs from that in the fundus
of the gall bladder. If the bile in the gall bladder emptied and
filled several times in each twenty-four hours, i. e., after each meal,
it should have the same specific gravity as the bile in the cystic
duct, which is not the case. Further, the bile in the cystic duct,
has the same specific gravity as that in the hepatic and common
ducts which shows that only this small quantity changes with the
contraction and dilatation of the gall bladder. This degree of con-
traction and expansion is very limited, depending on the degree of
tension of the bile circulation. After ligation of the cystic duct at
its junction with the gall bladder, and extirpation of the latter, it
has been found that in a number of months the cystic duct be-
comes much dilated, resembling a miniature gall bladder, Oddi. I
have verified this by one experiment.
Experiment III. — Dog, male, weight thirty-five pounds. May
14, 1892, cholecystectomy, silkworm gut ligature of adhesions to
liver; subsequent section, silkworm gut ligature of ductus cysticus,
top sewing peritoneum. The dog was sick for the first forty-eight
hours, after that he rapidly improved and in four days he was ap-
parently as well as ever. No jaundice. June 12, the dog has be-
come very fat and is the most playful dog in the laboratory. August
31, dog killed. The cystic duct was found to be dilated to a glob-
ular sac, five-eighths of an inch in diameter.
After a gall bladder and intestinal fistula has been established,
gradual contraction occurs; the gall bladder contracts to a tube not
much larger- than the cystic duct, as the element of tension is here
entirely removed. This change requires several weeks. I do not
know that dilatation of the cystic duct after cholecj'^stectomy has
been observed in man; it is possible that it does not occur since in
man there is no sphincter muscle at the opening of the common
duct into the intestine, as in the dog. The tension theory of the
gall bladder is further supported by the mechanical relations of
the gall bladder and cystic duct to the hepatic and common ducts.
It will be noticed that they occupy the same relative position to
the current of bile passing along the hapatic and the common ducts
that the air chamber in the fire engine does to the stream of water
flowing from the pump to the hose. The elasticity of air in the
small air chamber contributes greatly toward producing a con-
tinuous instead of a pulsating stream, as would occur with the
strokes of the piston, were there no elastic chamber. In place of
the air in the case of the gall bladder we have the elasticity of the
walls of the viscus itself, which keeps up the continuous pressure
by its expansion and contraction and thus acts as a tension con-
troller of the bile circulation. The gall bladder is congenitally
absent in a considerable number of animals and men, and its ab-
sence appears to have no appreciable effect on the health of the
organism. I have gone into the details of this somewhat thoroughly
because a clear understanding of the physiological principles is
necessary in order that we may better judge the most desirable
operations to be performed under given circumstances.
The various pathological conditions of the gall tracts which
necessitate operative interference requiring laparotomy, to which
line of operations this paper will be confined, I will only mention
by name, and will not go into the details of each. In the order of
frequency with which they produce disturbances they should be
classified as follows:
1. Cholelithiasis, gall stones; a, in the gall bladder; b, in the
ductus choledochus; c, in the ductus cysticus; d, in the ductus
hepaticus; e, in the diverticula; f, ulcerative perforation into the
peritoneal cavity.
2. Cholecystitis, empyema, hydrops.
3. Cancer of the pancreas,
4. Neoplasms involving the ducts.
5. Carcinoma of the gall bladder.
6. Traumatism.
OPERATIONS.
The operations on the gall tracts after the abdomen has been
opened are well divided into ten classes, viz.:
1. Puncture of the gall bladder.
2. Incision into the gall bladder without further operative
procedure.
3. Suture of the gall bladder to the abdominal wall with
secondary incision, cholecystostomy, two sittings.
4. Suture of the gall bladder in the abdominal wall with im-
mediate incision, cholecystostomy, one sitting.
5. Incision of the gall bladder, removing its contents, im-
mediate suture of the gall bladder and suturing it in the wound
of the abdomen, cholecystotomy.
6. Incision of the gall bladder with immediate suture and
reposition in the abdomen, cholecystendysis, ideal cholecystot-
om5^
1. Cholecystenterostomy, gall bladder and intestinal fistula.
8. Cholecystectomy. Removal or apiputation of the gall
bladder.
9. Choledocholithotripsy or crushing of gall stones in chole-
dochus.
10. Choledocholithectomy, with subsequent suture of duct.
INDIVIDUAL OPERATIONS.
I. Puncture of tJie Gall Bladder. — The puncture of nonadherent
gall bladder after opening the abdomen has been performed but a
very limited number of times (twenty-five), and through error in
diagnosis in the greater number of cases. Eight times the opera-
tion was performed for its therapeutic effect, after the abdomen had
been opened. Four of these eight were supposed to be circum-
scribed hydrops of the peritoneum; two of these cases terminated
fatally. In the other four, the diagonis was clear and the object
of treatment was to relieve the patient by aspirating the gall blad-
der. The cause of the dilatation was in three, cancer of the pan-
creas; in one it was due to calculus in the cystic duct. The final
outcome in one case was unknown; one of the cases died of ex-
haustion after repeated puncture; in the other two cases cholecystot-
omy was performed, one of two died. We have here then a fatality
of twenty-five per cent from simple puncture of the nonadherent
gall bladder. In the other seventeen cases the puncture was purely
explorative. Puncture of the gall bladder from the surface of the
abdomen without incision was suggested by G. Harley for the pur-
pose of sounding for gall'stones. He pronounced it an easy and
safe method for sounding for impacted stones, but his patient died
twenty-four hours after the operation of "enteritis and peritonitis."
This operation is to be condemned first, because there is great
doubt that a diagnosis can be made with a needle, even if a stone
is present. Second, a needle puncture of the gall bladder is danger-
ous because the opening remains patulous, as I have frequently
«een following aspiration preparatory to insertion of the button,
from an absence or very limited contractile power of the tissues of
the wall of the gall bladder and from tension by the bile pressure
within. Third, if the contents of the gall bladder in the case should
be septic, we would have as a result a septic peritonitis. Cour-
FiGURE 1. — Drainage tube button illustrating half of button threaded for intro-
duction into gall bladder.
voisier says, "that a surgeon should even hesitate to aspirate a case
where the diagnosis of gall bladder lesions was even suspicious,
and never except where no other means of diagnosis is left, a lap-
arotomy being a much more rational and safe method."
II. Incision of the Gall Bladder Without Further Operative Pro-
icedure. — This operation is performed for and should be limited to
cases where the gall bladder, on account of the gangrene of its
wall or extensive adhensions all around it render it impossible to
either suture it to the abdominal wall or approximate it to any por-
tion of the intestinal tract, and where it is compulsory to secure
drainage of the bladder or to use the bladder as a canal to allow
the escape of bile in obstructive jaundice, that jeopardizes the life
of the patient. A drainage tube may be inserted in the incision of
the gall bladder and packed around with gauze (Maurice H. Rich-
ardson), the omentum drawn about it with a few sutures to prevent
the fluid passing into the peritoneal cavity, or what is still better,
my method of insertion of a "button tube drainage," of the pattern I
here present, Fig. 1. This has the advantage; (1,) that it can be
easily and rapidly inserted deep in the abdominal cavity, though the
gall bladder may be very much contracted; (2,) that it prevents with
certainty the contact of the gall bladder contents with the abdominal
viscera until such time as adhesions have formed around the tube;
and 3, that it leaves a large opening,when the instumentis withdrawn
from the gall bladder, through which calculi may be extracted.
The operation with the "button tube" is performed as follows: An
incision is made in the abdominal wall in the usual position for op-
erations on the gall bladder beginning at the ninth costal cartilage,
parallel to the external border of the rectus muscle for a distance
of two and one-half inches. The gall bladder is located, a suffi-
cient surface of its wall exposed, the contents aspirated, the purse-
string suture inserted, the gall-bladder incised, male half of button
inserted, purse string tied and cut short; the tubular portion of
the button is then pressed into position; the tube is then drawn
out as far as the gall bladder will permit and held there with a pin
passed through the openings in the side. During the time the
pressure atrophy in the portion of the gallbladder clasped between
the button is taking place, a cicatricial wall is being formed about
the tube which acts as the walls of a sinus after its production and
insures continued protection to the peritoneal cavity.
The following operations were performed:
Case I. Mrs. K., aet. thirty-five, several children. This case
was referred to me by Dr. J. H. Hoelscher who furnished the fol-
lowing history : Four years ago the patient was first attacked
with severe pain in the region of the gall bladder, which was soon
followed by nausea and vomiting. This pain lasted several hours
and a few days after the onset the patient became very much jaun-
diced. Tenderness continued over the gall bladder for ten days
or more after the attack. Thiese attacks occurred at frequent in-
tervals during the past fouryears; after some of the attacks she
passed gall stones and has a collection of them on hand. About
two years ago she had one verj^ severe attack lasting much longer
than the others and accompanied by more pain, fever and tender-
ness. It took her a long time to rally from this attack. The last
attack, ten days before operation, was followed by jaundice and a
few stones were passed. Not more than half of the attacks were
followed by jaundice. She suffered very much most of the time
from digestive disturbances and a constant aching in the side.
Present Condition. — Patient a well nourished, stout, healthy-
10
looking individual. On examination we find a large sensitive tumor
extending, down about three inches below the right ninth costal
cartilage. This tumor can be felt separate and distinct from the
kidney, and presses against the abdominal wall in front. It moves
synchronously with the diaphragm in respiration.
Diagnosis. — Cholelithiasis with pericystitis. Operation by Dr.
Murphy, assisted by Drs. Hoelscher and Lee. Present, Dr. Mac-
Fadden Gaston, of Atlanta; Dr. Quimby, of Jersey; Drs. Cole and
Owings, of Montana; Dr. Jelks, of Hot Springs; Drs. Wittwer,
Hartmann, E. H. Lee, Conley and Oswald. The usual incision
was made at outer border of rectus. The gall bladder was com-
pletel}^ surrounded by adhesions and contracted: it was impossible
to approximate it to the abdominal wall or to any portion of the
bowel. It was decided to put in the drainage button tube. A
portion of the fundus of the gall bladder was exposed sufficiently
large to insert the button and to place it in position. A number of
calculi were removed and many allowed to remain. The tube pro-
jected above the wall of the abdomen, and the wound outside was
packed with iodoform gauze. The button tube liberated itself on
the seventh day, and a number of stones followed. The patient
made an uninterrupted recover}^, and is now in excellent health ;
has a small sinus, but no bile is escaping, August 20, 1893. Sep-
tember 15, sinus closed.
Case II. Mrs. M , set fifty, Indianola, Neb.
Diagnosis. — Cholelithiasis, impaction in choledochus. Had had
repeated attacks of gall stone colic, accompanied by jaundice, in
the last four years. For the last year the jaundice has been con-
tinuous.
Operation. — November 1, 1893. Found gall bladder very much
contracted; filled with a dozen calculi. Firmly adherent through-
out; evidence of old pericystitis. Duodenum adherent. As the
approximation to duodeum could not be made, the gall bladder was
incised, stones removed and the drainage tube button inserted and
packed around with iodoform gauze. The button tube liberated
itself on the tenth day. Two calculi followed it, which evidently
had been returned from the ducts into the bladder. Jaundice dis-
appeared. Sinus closed on twenty-first day. Patient about the
ward on twenty-eighth day. Discharged from the hospital De-
cember 6.
The number of cases of operation by incision and drainage in
literature is twenty-three, with four deaths, a mortality of about
eighteen per cent. As this is not an operation of election, the pe-
11
culiarities of the individual case will be the guide to the surgeon as
to when it must be performed.
III. Suture of the Gall Bladder with Secondary Incision, Chole-
cystostoniy in Two Sittings. — The serous surface of the gall bladder
is united to the margin of incision in the abdominal wall and a suf-
ficient time is allowed to elapse for adhesions to take place, from
five to fifteen days; then an incision is made in the gall bladder
and its contents allowed to escape. The operation was first sug-
gested by Carri, and executed by Blodgett and Kocher in 1878.
Courvoisier collected thirty-two cases. Riedel operated in this
manner thirty-four times, eleven of these are included in Courvoi-
sier's report. I find in the literature from June, 1890, at which
time Courvoisier's report was published, to February 28, 1893, but
four cases, with the exception of those of Reidel, twenty-three
cases, making a total of fifty-nine cases, with six deaths, or a mor-
tality of ten per cent. Of the patients that left the hospital, about
thirty-four per cent were discharged with a fistula; these had an
average treatment of two and one-half months. Riedel has cham-
pioned this operation from the beginning and has persistently
adhered to it while other surgeons have taken up the operation of
one sitting, as shown by the statistics, only four operations of this
kind being reported since June, 1890. Bardenheuer, Langenbuch,
Mikulicz and Lauenstein have been strong advocates of this ope-
ration in the order mentioned, but have all deserted it, notwith-
standing its favorable statistics, leaving Riedel alone its great
advocate. The indications for this operation are the same as for
cholecystostomy of one sitting, to be mentioned hereafter.
IV. Cholecystostomy in One Sitting, Suture with Immediate In-
cision.—The first operation of this kind was performed on July
15, 1867, by Bobb, who was making a laparotomy on the diagnosis
of ovarian tumor, this being the first laparotomy opening of the
gall bladder and cholecystostomy of one sitting. Without a
knowledge of this case, in the years 1878 and ]879, Marion Sims,
W. W. Keen and Lawson Tait performed the same operation
without previously diagnosticating the case. This operation was
named by Lawson Tait "ideal cholecystostomy." It would be
more appropriately termed unnatural cholecystostomy, as it is not
natural for the gall bladder to empty on the surface of the abdo-
men. The term "natural cholecystostomy" should be reserved for
the operation known as cholecystenterostomy, because the bowel
is the natural receiver of the contents of the gall tracts. From
that time there have been collected by Courvoisier 120 cases, by
12
Riedel 12 and by myself 69, making a total of 201 cases. The
histories of many of these cases are very defective, first, as to the
previous conditions; second, as to the status praesens and clinical
history; third, as to the condition when discharged. Tait operated
upon fifty-seven of these cases. In the very great majority he
leaves out all the particulars above mentioned. In many he does
not mention whether the fluid contents of the gall bladder was
bile, hydrops, or pus, and in others he does not mention even the
presence or absence of stone, though this item is less frequently
omitted. I find in 163 cases stones reported in 112, and in about
'75 per cent of these the stones were situated only in the gall blad-
der; in about 12 per cent in the gall bladder and cystic duct;
8 per cent in the cysticus alone; 3 per cent in the choledochus,
and the balance scattering. In all cases where found, the
stone was extracted from the gall bladder at time of operation.
In other cases where stones were situated in the ducts, a litho-
tripsy was performed either by the fingers, by forceps, or bj'^ pass-
ing a needle through the wall of the duct and fracturing the stone.
In other cases the stones were pressed onward out of the duct into
the intestine or back into the gall bladder; in still others thej^ were
cut down on in the duct and removed through its wall. Of this I
will speak later. The mortality in the 201 cases of cholecystostomy
while the patients were still under treatment, was 39 or about 19
per cent. The number of cases discharged with fistula can-
not be approximately determined as Tait's report is incomplete
and excluded. From other statistics we have discharged with
fistula about 31 per cent, and with the same exclusion as above
complete recoveries 51 per cent. We see that the mortalitj^ in the
one sitting was less than in the two sittings operation, in one case
being 10, and the other 19 per cent, but still the outcome as to the
ultimate complete recovery is approximately the same as in the
operation of one sitting, and not a promising one for the patient.
Still some surgeons have had brilliant results, and the renowned
Dr. H. G. Marcy, of Boston, says: "It is safe to predict that the
future history of operative measures for the relief of biliary ob-
structions, will furnish one of the most brilliant chapters in
surgery. One of the most serious of all the abdominal diseases,
as evinced by acute pain, prolonged suffering, and great mortality?
confessedly without remedy b}^ internal medication, cholecystost-
omy offers help to the hopeless with an attendant danger in the
hands of an experienced surgeon of as small a percentage as in
ovariotomy."
13
Cholecystostomy by Means of Murphy Button. — This operation
can be performed with the anastomosis button in much less time
and with much greater safety than with suture, in the following
manner: The half of the button that is to be introduced into the
gall bladder is first threaded by passing two pieces of surgeon's
silk about eighteen inches long through the four drainage openings
in the bowl of the button, each thread being passed through two of
the openings nearest one another, the four ends of the threads are
drawn even and then passed through the cylinder of the button,
entering the cylinder at its junction with the bowl. This enables
traction to be made on this half of the button after it has been
placed in position in the gall bladder, thus permitting a firm ap-
proximation and locking of the two halves of the button. The
threaded half of the button is inserted into the gall bladder in the
same manner as in cholecystenterostomy; an artery forceps is then
pushed through the parietal layer of the peritoneum, one-half inch
to the side of the incision, grasping the stem of the button inserted
in the gall bladder and drawing the stem through the opening
iViade by the artery forceps; pass the traction cord through the
other half of button, draw the button together and remove the
threads. Sew up original opening in the peritoneum with catgut.
You have now secured a firm, permanent approximation of the sur-
face of the gall bladder to the parietal layer of the peritoneum.
The gall bladder will drain through the button, and if the button
drainage tube is used the discharge can be brought to the sur-
face, without coming in contact with the wound. This operation
has the advantage over the suture approximation; 1, in the
great saving of time; 2, simplicity and ease with which it can
be accomplished; 3, it insures perfect coaptation and no danger of
leaking at the side, or giving way, as is the case is with the suture
which occasionally causes death; 4, it leaves a large opening. As
soon as the pressure atrophy is completed gall stones may be ex-
tracted through this opening and a perfect drainage kept up. I
am always in favor of performing cholecystenterostomy where it
is possible, still if the pathological conditions require a chole-
cystostomy, this is by far the most simple, rapid and safe means of
operating,
V. Incision, of the gall bladder, removing its contents, suturing it
to the abdominal wall with immediate extraperitoneal suture of the
incision made in the gall bladder.
I am unable to find but four cases of this kind reported. The
operation has never found great favor with surgeons. Of the four
14
cases operated on, three terminated successfull}'^, and one fatally, a
mortality of twenty-five per cent. It was intended to take the
place of cholecystendysis, and to diminish the danger by having
the suture in the gall bladder extraperitoneal, so that if the suture
should give way or leak, the contents would escape on the surface
instead of into the peritoneal cavit)'.
VI. Cholecystendysis. — Incision of gall bladder with immediate
suture and reposition into abdominal cavity : ideal cholecystotomy.
This operation on the gall bladder is a natural outgrowth of the
desire of laparotomists to immediately and permanently close the
abdomen at the time of the operation as in the intraabdominal
treatment of pedicles in gynecological operations. I find thirty-
five cases of this kind in the literature, with eight deaths and
twenty-seven recoveries, a mortality of twenty-three per cent.
The cause of death was : In one case collapse, in two cases anuria
with collapse, three with high fever and peritonitis. All of the
immediately fatal cases, six, or seventeen per cent, terminated with-
in seventy-two hours after the operation. The remaining two ter-
minated later. What was most feared in this operation was that
the stitches would give way under the tension of the gall pressure
and that the contents of the gall bladder would escape into the
peritoneal cavity. Langenbuch and Tait were very loud in their
declaration that this accident would occur, and Tait in his article
in the Edinburgh Medical Journal, October, 1889, stated that the
operation terminated fatally in every instance, while in reality up
to that time there had been sixteen operations, with ten recoveries,
and in not one of them did the accident, "giving way of sutures,"
as Langenbuch and Tait had predicted, occur. This is a very
noticeable illustration of an error of common occurrence. It shows
how erroneous the opinions of great men in surgery may be on
operations suggested and performed which are not in line or in
harmony with the ones they are accustomed to perform, the calam-
ity which they so forcibly predicted and deemed inevitable was the
one that never occurred. While the cause of death was not from
giving way of sutures the mortality was great, being about one-
third of all cases operated on. This great mortality has rapidly
told against the operation, so that it is now rarely performed and is
not to be recommended.
VII. Cholecystenterostomy. Gall Bladder and Intestinal
Fistula — Gall Bladder and Intestinal Anasto/nosis. — The idea of this
operation was suggested by nature in establishing pathologically
a fistula between the gall bladder and the intestines. In this way
15
the surgeon was guided to the best means of relief where an occlu-
sion of the duct was produced by the pressure of an impacted con-
crement, a neoplasm, a cicatricial band, or any pathological lesion
which would render the common duct impervious. While nature
had thus blazed the way, surgeons were slow to take advantage of
its suggestion. The first one to advise this method was my late
friend, the lamented von Nussbaum, of Munich in 1880. He ex-
pressed himself in the following words: "When the escape of gall
through the natural duct is no more possible, the question arises
can we not make an artificial connection between the gall bladder
and intestines through which the gall can again escape into the
intestinal tract," etc.
The first to work out a feasible plan for the attainment of
this ideal result was von Winiwarter. Between the 20th of July,
1880, and the 14th of November, 1881, he had under his care a
man, with occlusion of the ductus choledochus, on which he oper-
ated six different times, and finally succeeded in establishing a
fistula between the colon and the gall bladder, after 16 months of
labor. His original plan was to perform the operation in two sit-
tings, but all sorts of difficulties beset his way. It is wonderful
what energy and persistence both the operator and patient showed
to overcome all impediments. After the publication of his most
difficult task it was six years and a half before a surgeon was found
who had the courage to undertake a similar operation, when Kappe-
ler undertook to follow in the footsteps of Winiwarter, but to do
the operation in one sitting.
In the meantime there were several experiments made on ani-
mals, with the hope of discovering a means of making a communi-
cation between the gall bladder and the intestine at one sitting.
Dr. McFadden Gaston, in 1883, experimented on five dogs, with
elastic suture, which was so placed as to approximate the gall blad-
der and intestines, and around this a row of serous sutures to pro-
tect the peritoneum. He hoped by the elastic pressure to produce
an atrophy and establish a fistula. The results were unfavorable.
In one the dog escaped; two ended in peritonitis; one in abscess
between coils of intestine — here the ligature sloughed through into
the gall bladder, and left but an extremely small opening; and in
one, at the end of the eleventh day, there was found sufficient ad-
hesion and the fistula was established, the ligature being found in
the intestine. In 1884 he used a similar ligature on a young dog,
in the same manner, with a good result. In 1886 he made several
similar experiments, with the addition of ligatingthe common duct,
1(1
but the dogs ouly lived a few days, dying of extensive gall infiltra-
tion in the liver. He deserves great credit for energy and inge-
nuity as a pioneer in this field.
G. Harley suggested the approximation with the formation of
fistula from the gall bladder to the intestine by means of sutures
and caustic potash. He arranged a number of sutures in a small
circle, about the size of a dollar, holding the gall bladder to the
bowel, but before completing the circle mentioned, cauterized the
center with caustic potash, then completed the circle with sutures,
and in that way hoped to produce a fistula of the gall bladder and
hava an adhesion by plastic exudation surrounding it. He claims
to have had good success in animals.
Colzi, in 1883, put in a circle of sutures similar to Harley's,
but before the final suture, made an incision in the center into the
gall bladder and duodenum, also ligating the choledochus. The
animals tolerated the operation without any apparent disturbance
in the digestive functions.
De Page, in 188*7, performed the same experiment as Colzi, on
three dogs, without ligating the choledochus. In one the dog ran
away; another died of peritonitis; the third was killed at the end
of six weeks and showed an atrophy of the gall bladder, but no
fistula. Finally, Dastre, in his communication to the Physiological
Congress at Basel, in 1889, published his experiments, wherein he
succeeded in uniting the gall bladder to the intestine for the pur-
pose of studying what effect it would have on digestion. Of this
I shall speak later.
So that we see to the date ^bove mentioned experiments rep-
resented three different t5'pes. 1. The formation of fistula by
chemical destruction. 2. By pressure atrophy, the elastic ligature.
3. Careful suturing with subsequent incision within the circle pro-
duced by the sutures.
The priority of the operation certainly belongs to Monastyrski,
for he performed his operation about a month before Kappeler, but
did not publish it until eleven months after the operation. Of the
seven operations performed, four were for carcinoma of the head
of the pancreas, one for carcinoma of the duct at its orifice, and
two were for impaction of gall stones; those of Terrier and Cour-
voisier. The technique in all of the above described operations
was somewhat similar, the suture being, used as the means of ap-
proximation. Terrier used a rubber tube to keep the opening patu-
lous which was passed on the eighth day. The seat of the operation
in Terrier's case was the duodenum; in JNIonastyrski's, the jejunum.
\1
2 in. below the duodenum; in Kappeler's, 226 ctm. above the cecum;
in Fritsche's case 3 in. below the pylorus.
There remain the cases of Bardenheuer, who performed two
operations where he united the gall bladder to the small intestine
with an elastic suture in the center and a single row of silk sutures
around it, expecting that the elastic suture, would produce a
pressure atrophy, and that a fistula would remain. The first case,
impacted gall stones, terminated fatally at the end of four weeks,
and the fistula was not yet established, nor had the gall bladder ad-
hered to the intestine, a biliary fistula opening into the peritoneal
cavity. The second he writes to Terrier, was done in the same
way, with the same result. To this list, taken from Courvoisier,
may be added two^^by Czerny, one of which died of hemorrhage,
and the other from exhaustion; one by Helfreich and one by Reclus,
making up to date, November, 1892, in all thirteen cases of chole-
FiGURE 2. — Anastomosis Button.
cystenterostomy of one sitting. Of these six died as the result
of operation — Fritzsche's, two of Bardenheuer, two of Czerny, one
of Korte, five died as the result of the malignant disease from which
they were suffering; and two survived. Terrier's and Courvoisier's;
making a mortality of forty-six per cent as an immediate result of
the operation.
Since November, 1893, I have collected twenty-three cases
with eight deaths; mortality thirty-five per cent.
The various operators in commenting on the technique of the
operation, all agree that it is one of extreme difficulty; and while
the experience of the others was not as trying as that of Wini-
warter, it was always most difficult of performance with suture
and occupied an hour or upward to complete the operation.
While reading of the great difficulties experienced by the op-
erators mentioned in performing this operation, I realized that the
profession was sorely in need of some more simple and perfect
means for the approximation of the gall bladder and the intestine;
and, after trying several devices, I succeeded in producing and per-
18
fecting the anastomosis button, which I think fulfills all of the indi-
cations, Fig. 2. The button is inserted in the following manner:
An incision is made from the edge of the rib, two inches to
the right of, and parallel to, the median line, extending downward
three inches. The gall bladderis drawn into the wound, also the
duodenum. The duodenum is cleared of its contents b}^ gentle
pressure with the fingers. My short intestinal compression forceps
are placed upon the duodenum to prevent the escape of gas and
fluids after the incision is made. A needle with fifteen inches of
silk thread is inserted in the duodenum, directly opposite its
mesenter}^ and at a point near the head of the pancreas. A stitch
is taken through the entire wall of bowel, one-third the length of
the incision to be made. The needle is again inserted one-third
the length of the incision from its outlet, in a line with the first,
Figure 3. — Intestinal Compression Forceps.
and brought out again, embracing the same amount of tissue as
the first. A loop three inches long is held here, and the needle is
inserted in a similar manner, making two stitches, parallel to the
first, in the reverse direction, and one-eighth of an inch from it,
coming out at a point near the original insertion of the needle.
This forms a running thread, which, when tightened, draws the in-
cised edge of the bowel within the cup of the button. In the gall
bladder a similar running thread is inserted. Fig. 4. An incison is
now made in the intestine, in length two-thirds of the diameter of
the button used. One part of the button is slipped in, the running
string tied, and the button held with the forceps. The contents
of the gall bladder is withdrawn with an aspirator. An incision is
then made in the gall bladder the same length, and between the
rows of sutures, the other part of the button is inserted in a similar
19
manner, and the running string tied. The forceps are removed and
each half of button held between the fingers and pressed together,
Fig. 5. 'A sufficient degree of pressure must be used to bring the ser-
ous surfaces of the gall bladder and intestine firmly in contact and
compress the tissues. The elastic pressure of the spring cup of
the button produces a pressure atrophy of the tissue embraced
within the cup, and leaves an opening as large as the button, the
button dropping into the bowel and being passed through the in-
testines.
Figure 4. — Running threads in position in gall bladder and duodenum.
It takes about as long to describe the operation as to perform
it. The time occupied with the first patient on whom I operated
was eleven minutes, from the entering of the peritoneal cavity until
the closing of it. On dogs I was from eleven to eighteen minutes
in performing the operation, the latter time being on the first dog,
before I had made the various improvements in the technique and
button. The operation is more difficult to perform on the dog than
on man, as it is more difficult to bring the gall bladder into the
wound.
To show that this operation is one that the busy surgeon will
be frequently called upon to perform, now that the technique is
20
simple, we have only to reflect on the number of cases of chronic
jaundice from obstruction of the common gall duct, requiring some
operation for relief, and to draw attention to the defects of the op-
erations now in vogue, namely, the unpleasant and sometimes dan-
gerous sequence of cholecystostomy, an external biliary fistula,
which may of itself be a menace to life, and require a second
Figure 5. — Method of controlling the two halves of button while
approximating.
operation even more critical than the first, as is shown in the re-
ports by Courvoisier; also the difficulties and dangers of cholecyst-
ectomy and cholecystendysis.
When we consider that in cholecystostomy patients re-
quire two operations and that the quantity of bile discharged in
each case requires at least two dressings a day for two and one-
half months, representing an enormous amount of labor for the
21
surgeon and attendants and a very protracted and unpleasant con-
valescence for the patient; also, when we consider that but fifty-
one per cent left the hospital with complete recovery, we can see
how very much the profession is in need of some better plan of treat-
ment of the lesions of the gall tracts than cholecystostomy by
one or two sittings. Take into consideration also the injurious ef-
fects of a permanent fistula and we have another very potent reason
for abolishing the external opening.
The effect of a permanent fistula of the gall bladder and con-
stant escape of bile secreted, as frequently follows cholecystostomy,
is different, depending first, on the quantity of bile that escapes
from the opening, and, second, on what proportion is admitted in-
to the intestinal tract. These facts have been lost sight of by
many of the surgeons that have operated and had an external
fistula remain, which accounts for the great differences of opinion
as to the gravity of a biliary fistula. Where the fistula of the gall
bladder allows only a portion of the bile to escape, the patient and
animal, as in Dastre's experiments, can live without suffering from
the loss; that is, they are capable of digesting with a much smaller
quantity of bile than they naturally secrete. But if we let the en-
tire quantity of bile escape through a fistula, the patient soon
succumbs. This is thoroughly demonstrated by the twelve cases
collected by Courvoisier. All patients died where the entire
quantity of bile secreted escaped through the fistula, and where a
large proportion escaped the patients became emaciated and sick.
Therefore a safe means of allowing the bile to reenter the intes-
tines should be welcomed by the surgeon and patient. This opera-
tion will produce the same favorable revolution in the surgery of the
gall bladder that the intraabdominal treatment of the pedicles did
in the treatment of tumors of the uterus and its appendages.
Why should a gall bladder be sutured to the abdominal wall
and drained any more than an ovarian cyst should be treated in
this manner ?
There are reported in all up to December, 1893, twent)'-three
cases operated on in one sitting all b}^ means of sutures, with a
mortality in this operation of thirty-five per cent, or eight deaths
in twenty-three cases. From the 11th of June, 1892, up to Febru-
ary 13, 1894, there have been twenty operations of cholecysten-
terostomy by means of the anastomosis button for the relief of
cholelithiasis, with twenty recoveries, 100 per cent, one each by
Dr. E. W. Lee, Chicago; Dr. W. J. Mayo, of Rochester, Minne-
sota; Dr. A. H. Fabrique, of Wichita, Kan. ; Dr. Alex. H. Ferguson,
22
Winnepeg, Manitoba; Dr. W. B. Rodgers, Memphis, Tenn.;
Dr. T. D-. Lane, Media, Penn.; Dr. Wm. D. Foster, Kansas Cit}';
Dr. J. H. Dunn, Minneapolis; Dr. M. H. Luken, Chicago; two
by Dr. F, S. Hartmann, Chicago, and nine by myself. In all of
these cases the result has been a complete restoration to health
and no recurrence of symptoms, as will be seen by the histories.
I have had all of my cases and those of Drs. Lee and Hartmann
visited in the last week, and the}^ are all in excellent health; in not
one did the symptoms return as was feared by Dr. Abbe. There
was one operation by this method, by myself, in which the lesion
was carcinoma of the pancreas. The duodenum was involved in
the carcinoma and could not be used in approximation, a loop of
the small intestine was drawn into the opening in the abdomen and
approximated to the gall bladder with the button, and the patient
died at the end of the fouith day. The post-mortem showed the
button in position. It was found that the bowel had been twisted
upon itself in the operation and a complete obstruction produced
the same as in volvulus. This accident is an impossibility if the
duodenum is used for the approximation, and I wish to call special
attention to its liability, as it is so easily avoided when it is antici-
pated. There was a cancer in this involving the greater portion
of the pancreas, including the duodenum, and the common duct.
The period of convalescence was in all cases very short and the
patients were not seriously sick immediately after the operation.
This operation is indicated : 1, in all cases where it is desira-
ble to drain the gall bladder for accumulations therein ; 2, in all
cases of perforation of choledochus into abdominal cavity where
the duct must be obliterated by the reparative process ; 3, in all
cases of cholelithiasis where obstruction of ducts is present, or
where the reflex disturbances of digestion are marked ; -i, in all
cases, of cholecystitis either with or without gall stones; 5, and in
all profusel}' discharging biliary fistulae, either following operations
or as sequelae of pathological changes in gall tract.
The cases in which this operation should not be performed
are : a, all cases where the gall bladder is too small for the inser-
tion of the button ; b, where the adhesions are so extensive that
the bowel cannot be brought into contact with the gall bladder
without kinking ; c, where the ductus cysticus is obliterated, in
which cases the operation of cholec3^stectomy should be performed
where there is an absence of adhesions around the gall bladder ; d,
where we have an enormously enlarged gall bladder with an
elongation of the ductus cysticus, and without an obstruction in
23
the ductus choledochus, in which case cholecystectomy should be
performed. If the ductus choledochus be occluded, the gall blad-
der should be amputated just above the neck, leaving a sufficient
portion in vi^hich the button can be inserted in the end, and the
approximation made to the duodenum in the usual way. By this
operation we provide again a channel for the escape of the bile
into the intestinal canal.
REPORT OF CHOLECYSTENTEROSTOMIES BY MEANS OF THE
ANASTOMOSIS BUTTON.
Case I. A. Q , age thirty-five, female; admitted to the
medical department of Cook Count)^ Hospital, May 27, 1892.
Transferred to the surgical division of the hospital, June 10, 1892,
and came under my care. Gave the following history : During
the last fifteen years has had stomach troubles ] pain and tender-
ness in the epigastrium ; the attack would last from two to four
days, was almost always accompanied by vomiting, not by jaun-
dice. Had pain in back since childbirth; suffered from chronic
constipation. One of these attacks was accompanied by jaun-
dice, December 14, 1891. At that time had constant and intense
pain for twelve hours, and an aching pain and tenderness in the
epigastrium for two months following it. Jaundice cleared in about
two months. During the past few months the attacks of stomach
trouble would last from twelve to twenty-four hours. In February
the present attack began, accompanied by jaundice and severe
pruritus, which has been constant from that time up to date.
These symptoms increased in severity up to the time she was
admitted into the hospital. While in the medical department her
jaundice was constant ; her mental condition became very much
impaired, and her emaciation rapidly increased.
Condition when admitted to the Surgical Department: The
patient intensely jaundiced ; very much emaciated ; has a point
of tenderness in the right hypochondriac region just below the
margin of the rib ; no tumor to be felt. The urine contains a
large quantity of bile, no albumin. The patient suffers from
considerable mental derangement, very slight elevation of tem-
perature.
Operation June 1 1, 1892. I decided to perform cholecj'stenter-
ostomy by means of an anastomosis button, which device I had used
for the first time on a dog, six days previous. An incision three inches
long was made, three inches to the right of the median line, extend-
24
ing directly downward. The gall bladder was found distended,
nonadherent, and contained a large number of small calculi. Two
calculi were found in ductus choledochus and allowed to remain.
Duodenum and gall bladder were both drawn into the wound; an in-
cision was made in the duodenum and half of the button inserted. A
running thread was put in the gall bladder, an incision made,
and the other half of the button inserted. The gallstones were not
removed. There was considerable escape of bile, as gall bladder
was not aspirated before putting in the button. The button was
then pressed together without any difficulty, and the mass dropped
into the abdominal cavity. Time from the opening of the perito-
neum until the closing of same, eleven minutes. After the opera-
tion the patient showed no unpleasant symptoms ; temperature at
no time exceeded 100° F., and in fourteen days from the operation
she was allowed to walk about the ward. The jaundice rapidly
disappeared, and three weeks after the operation there was no
trace of bile in the urine. The patient was of a very hysterical
temperament after her mental condition improved ; she noticed
that she was an object of observation and became so erratic that
we could not control her at the hospital, and were compelled to
discharge her five weeks after the operation. Up to that time she
stated that she had "not passed the button." She was apparently
well in every particular. The button used in this case was very
imperfect compared with the improved one now used.
October 28, 1892. Patient was examined by Dr. H. R.
Wittwer. He found the jaundice had not returned; there was no
bile in the urine, and the patient was in excellent health. He
could not ascertain whether she had passed the button or not.
In December, 1892, this patient began to suffer from pain
in the right side and temperature which continued to Januar}^
1893. She was in one of the hospitals in this city. An explor-
atory operation was made over the site of the former operation,
a contracted gall bladder was found firml}^ and perfectly united
to the duodenum. Subsequentl}' the cause of the temperature
was found to be an abscess of the lung, not an empyema,
which was drained, and the temperature at once disappeared. At
no time since the first operation has the patient been jaundiced,
nor has there been bile in the urine.
Case II. The following case was referred to me by Dr.
Hoelscher, who with Drs. Wiener and Lee, assisted me in the
operation. Mrs. B , age thirty-eight, widow, three children.
25
Parents still alive, aged seventy-six and seventy-four respectively.
Brothers and sisters well; no history of any hereditary disease.
Dr. Hoelscher saw the patient for the first time October Y,
1892, and found her as follows: " Healthy, well nourished appear-
ance; pain of sudden onset in the epigastric region, and from this
point it gradually extended over the whole abdomen. She had
vomited the contents of the stomach and some bile on two oc-
casions after the seizure with pain. Bowels were constipated and
had been in this condition two or three days before the attack.
Vesical tenesmus and diminished quantity of urine. Gave no his-
tory of any previous pain, gastric disturbance, jaundice or colics."
On examination found a tumor in right hypochondriac region,
■extending downward into the iliac region and terminating in a
rounded smooth end ; could be distinctly felt in lumbar region, was
movable and tender on pressure; there appeared to be a deep fis-
-sure between the tumor and the liver, no fluctuation apparent,
bowel or colon not overlying the tumor. The diagnosis could not
be determined, but it was presumed to be some lesion of the kid-
ney, so it was decided to make an exploratory laparotomy.
Operation, October 19, 1892. I made an incision three inches
long, from the edge of the tenth rib directly downward toward the
border of the ilium. The tumor was exposed and found to be a very
much enlarged gall bladder containing large calculi. The viscus
was edematous, red and thickened. It was decided to make a chole-
•cystenterostomy with the anastomosis button. No. 2. The gall blad-
der was aspirated, and the running thread inserted. The running
thread w^as then inserted into the duodenum and the intestine in-
cised and the male half of the button placed in position; the female
half was then placed in the gall bladder through a slit made be-
tween the running thread, and the button closed. The gall blad-
der measured at least one centimeter in thickness and was very
edematous. There was no difjficulty in inserting the button. The
gallstones were allowed to remain, as I do not consider it neces-
sary to remove them unless the}^ are larger than the button. They
will pass out after the button escapes.
October 20. Temperature, 101° F.; pulse, 96. Vomited con-
siderably during the night and complained of headache, which
seemed to be effects of anesthetic. There was no pain nor ab-
•dominal tenderness.
October 21. At 5 P. M. yesterday the vomiting ceased, and
the patient is feeling very well this morning.
October 27. The patient has had no unpleasant symptoms
26
since October 20. This morning, eight da3's after the operation,
two large gallstones were found in the stool. The larger one
weighed llV grains, 1.8 gni.; its longest diameter one inch, its
shortest seven-eighths inch. The second stone 102 grains, 6. 8
gm.; its longest diameter seven-eighths inch, its shortest three-
fourths inch. It will be noticed that the shortest diameter of the
larger stone measures exactly the same as the diameter of button
used. The patient is feeling very well and is sitting up in bed.
Complete primary union. Button passed eighteen days after op-
eration.
August 20, 1803. The patient has excellent health and not
the least symptom of her previous trouble.
Case IH. This case was referred to me by Dr. J. H.
Hoelscher, who gave me the following history : "Mrs. Z , age
thirty-six, married, six children. Enjoyed perfect health until
twenty-two years of age; at that time, three months after childbirth,
had an attack, of short duration, of severe epigastric pain and
vomiting. It was not accompanied or followed by jaundice. Ever
since that attack she has had digestive disturbances, as distress
following certain kinds of food, eructations of gas, constipation,
loss of appetite. Four 37ears ago she had a similar attack of
pain in the epigastrium, accompanied by vomiting. From that
time on the pain returned every five or six weeks, up to five
months ago, when she noticed a constant aching pain and tender-
ness in the right hypochondriac region, that persisted until the
present time. The pain and soreness was very much increased
after working in a stooping posture. She has suffered much from
general debility, and complains frequently of slight chills.
Throughout the entire progress of her disease jaundice was
never present. The urine was tested several times with nega-
tive results. She does not give a distinct history of having
had hepatic colic.
"About three months ago she found small particles the size of
mustard seeds, in the feces, which some one told her were gall-
stones. There is no positive evidence that she ever passed a gall-
stone. Physical examination revealed heart and lungs normal;
liver not increased in size. Manipulation reveals a pear shaped,
hard tumor in the region of the gall bladder, measuring about three
inches in length, and two in width. It moves synchronously with
the diaphragm in respiration. On pressure considerable pain is
produced, and a slight creaking sensation is felt by the fingers.
27
It can be separated from the kidney, and can be moved considera-
bly from side to side."
The diagnosis of gallstone was made by Dr. Hoelscher, and
the case was referred to me for operation.
Operation, November 23, 1892. Assisted by Drs. Hoelscher
and Lee, in the presence of Dr. Nicholas Senn,Dr. Dunn, of Min-
neapolis and Drs. W. J. and C. H. Mayo, of Rochester, Minn.
The incision was made the same as in Case II.; a contracted
gall bladder packed full of gallstones, slipped into the wound.
A little difificulty was experienced in drawing the duodenum for-
ward, as some old adhesions existed. The running threads
were inserted in gall bladder and duodenum ; male half of button
placed in duodenum, and held by an assistant. An incision was
made in the gall bladder, which was found so full of gallstones
that half of the button could not be inserted without removing
some of them. A dozen were quickly picked out with the dissect-
ing forceps. About twice as many were allowed to remain. The
female half of the button was inserted in the gall bladder, and the
running thread tied. Button pressed together. Toilet of field of
operation was made with dry gauze, and the viscera dropped
back into the abdomen. Deep and superficial rows of sutures in
abdominal wall. Time for entire operation twenty-one minutes.
The time for inserting the button was not taken. Patient rallied
rapidly from the anesthetic. Pulse after operation 70 ; tempera-
ture normal. Neither nausea nor vomiting.
November 25. Pulse, 78; temperature, 100.5° F. Patient
complains of slight pain at seat of operation. No tympanites nor
abdominal tenderness.
November. 28. Patient expresses herself as feeling very well.
At no time since the operation has patient's temperature exceeded
100.5° F. She is allowed to take a quantity of liquid nourishment^
but not sufficient to satisfy the appetite. I consider her now out
of danger. Dr. Hoelscher is to be congratulated on his diagnosis
in this case in the absence of so many important S3'mptoms.
August 20, 1893. Dr. Hoelscher reports to me that this
patient has enjoyed better health since the operation than she had
for years previous. Not one of the symptoms returned.
Case IV. Mrs. F- , Referred to me by Dr. Hoelscher, who
furnished me the following history :
"Patient age fifty-six, married, has several children. For the
last four years has suffered from attacks of difficult breathing and
palpitation. These attacks were usually accompanied b}' pain
28
and tenderness in the right hypochondriac region. On three
or four occasions in the past year has had colic, and most of that
time was unable to work and was confined to her room. These
attacks were never followed by jaundice, or vomiting. Never passed
gallstones. On December 11, 1892, patient had a severe attack
of pain with vomiting, and great tenderness on pressure in the
right hypochondriac region. This continued up to the time of the
operation, but no jaundice was present, and no bile in the urine."
Dr. Hoelscher requested the operation of cholecystenterostomy.
Operation December 18, 1892. Dr. Murphy, assisted by Drs,
Hoelscher and Lee, performed cholecystenterostomy by means of
the button. A number of gallstones were removed. The button
was easily inserted. The abdominal wound dressed. The patient
was removed from the table in excellent condition. Her conva-
lescence was uneventful.
August 20, 1893. Patient called at office and reported that
she has enjoyed better health since the operation than for years.
Has not had a recurrence of the dyspnoea or palpitation. Has
gained very much in weight and strength. No recurrence of pain.
Case V. Mrs. D. W ., Called to see patient by Dr. T. J.
Conley, who furnished the following history: "Patient, widow, age
fifty-four. Has had several attacks of pain in the right hypochon-
driac region for the past two years. Two weeks before the present
attack suffered from a severe purulent bronchitis and was much
emaciated by it. Shortl}^ after the bronchitis subsided, she had an
attack of pain and pressure in the right hypochondriac region. She
never had an attack of jaundice.
*'0n examination January 29, 1893, patient emaciated; suffering
from bronchitis, pain and tenderness in the right hypochondriac
region; a small tumor can be felt in the same region. It is
movable and can be separated from the kidney."
Operation January 31, 1893. Dr. Murphy, assisted b}' Drs.
Conley, Lee, Hartmann and Wittwer, performed cholecj'sten-
terostomy. There was no difficulty in inserting the button.
Time nineteen minutes. The patient suffered very much from
vomiting for five days following the operation. Button passed on
the twenty-eighth day after the operation; two stones were also
passed. Highest temperature after operation 100. 5°F. This was
attributed to the bronchitis.
Dr. Conley, under date of May 8, 1893, wrote me the follow-
ing:
"Mrs. D. W., on whom you performed cholecystenterostomy.
29
is strong and enjoying very good health. Several times within the
last two weeks she has walked two miles without fatigue, 'iliere
is no tenderness or pain at the seat of the operation."
Case VI. History and particulars furnished by Dr. E. W.
Lee, in whose practice this case occurred. "Mrs. L , age forty-
eight, married. At intervals in the last three years patient has
suffered from severe attacks of colic, accompanied by nausea and
often vomiting. The pain was always located in the right hypo-
chondriac region and often in the 'pit of the stomach.' These at-
tacks would last for several hours, and then would suddenly disap-
pear, leaving a soreness at the seat of pain. They were never ac-
companied by jaundice until the present attack, which began Feb-
ruary 14, 1893, six days before operation. This attack was more
severe and prolonged than any of the previous ones. The vomit-
ing was very severe. The tenderness over the gall bladder was ex-
treme.
•'Operation February 20, 1893. Dr. E. W. Lee, assisted by
Drs. Murphy, Hartmann and Wittwer, performed cholecystenter-
ostomy by means of the button. The gall bladder was very i]iuch
contracted, and there were many adhesions. The adhesions were
separated and a medium sized button inserted, producing a perfect
approximation. Seven small stones were removed at the time of
the operation. The recovery was uneventful. Patient passed the
button March 6, fourteen days after the operation. A number of
small stones were passed subsequently.
"August 26, 1893. Patient has been able to work more since
the operation than for three years previous. Has had no colic or
digestive disturbances."
Case VH. Dr. William J. Mayo, Rochester, Minnesota, in a
personal letter furnished me the following history: "W. H ,
Racine, Minn., American, male, aet. 71. Patient gave a history of
colics for two years, jaundice for two months; great debility,,
cholemia, white stools, etc.
"Operation April 6, 1893, by Dr. W. J. Mayo, assisted by Drs.
C. H. Mayo and S. Plummer. Usual incision for operation on gall
bladder. No stone found in gall bladder; obstruction in common
duct. Cholecystenterostomy by Murphy button. Bladder could
not be brought to surface, obstruction could not be removed ; the
button was readily placed in position; no unpleasant S5'mptoms
since the operation."
This is a remarkable case on account of the age of the patient.
30
and the doctor deserves great credit for operating on a patient so
debilitated at the time of the operation.
Case VIII. From Dr. Wm. D. Foster, Kansas City, Mo. "Mrs.
A. M. S , aet. 58. Diagnosis, cholelithiasis. Operation Nov.
123, 1893, cholecystostomy. Gall bladder contained more than one
pint of fluid consisting of mucus and bile ; six hundred and
twenty-six gallstones removed which weighed six drachms.
Gall bladder was sutured to abdominal wall : subsequently the
fistula was closed with wire sutures; operation unsuccessful.
"Operation April 28, 1893, cholecystoduodenostomy by means
of the Murphy button. No attempt was made at the time to close
the fistula.
"Aug. 13, the fistula completely closed without operation.
The bile discharged into the intestine."
Case IX. M. D , Alexian Brothers Hospital. Transferred
to m}^ service by Dr. Hoelscher. Age 42, male, single. Several
weeks ago he began to have pain and a sense of pressure under
the border of the right ribs. This was sometimes accompanied by
severe pain, with nausea and vomiting, but no jaundice. One
week ago the pain became very much more severe, and was soon
followed by jaundice. Shortly after the jaimdice appeared the pain
ceased, but the tenderness remained over the region of the gall
bladder.
Siatus praesens. Icterus very marked, large quantities of bile
in the urine, feces acholic. Tongue dry and brown; temperature
100. 4°F; pulse 86, full and regular. The patient very tender over
the lower margin of the right costal arch. An induration could be
felt, but the gall bladder could not be outlined.
Diagnosis: Cholelithiasis with occlusion of choledochus.
Operation May 6, 1893. The patient acted very badly under
chloroform, so it took ten minutes to open the peritoneal cavity. The
gall bladder was aspirated and joined to the duodenum with the but -
ton in ten minutes, and ten minutes was consumed in making the toi-
let and suturing the wound, making thirty minutes in all. A small
stone was removed from the gall bladder, but the obstruction in the
common duct was not disturbed. The patient made an uneventful
and rapid recovery. The jaundice rapidl}^ disappeared after the
operation. The patient was up and about the ward on the fif-
teenth day. Voided the button on May 22, sixteen days after the
operation. The urine showed a negative reaction for bile May 14.
August 15, 1893. The patient reported at the hospital. Has
31
gained very much in weight and is enjoying excellent health. No
return of his symptoms.
Case X. Mrs. B , Rock Island, 111., admitted to St. Joseph's
Hospital, May 13, 1893. Patient was very much emaciated from
an illness extending over a period of six weeks. In the last two
years suffered from frequent attacks of pain in the right hypochon-
driac region, accompanied by vomiting. These attacks were not
followed by jaundice, except the last one, which began six weeks
ago. This attack continued with severe pain, vomiting, great ten-
derness over the region of the gall bladder. The temperature was
of an intermittent character, fluctuating every other day from
99° F. to 103° F. On the intervening day no temperature. The
elevation of temperature was frequently, but not always, preceded
by a chill.
Status firaesens. Patient slightly icteric, very much emaciated,
pulse 120, feeble but regular. Urine contains a considerable
quantity of bile; patient is nauseated when she sits upright. The
attacks of pain come on every few hours and are of a distinct
colicky character. There is present a tumor extending three inches
below the margin of the ribs in the right hypochondriac region,
and about three inches in diameter; it moves synchronously with
the diaphragm in the respiratory act, and is very sensitive on pres-
sure. It can be separated from the kidney, which is situated below
and behind, and does not move with respiration.
Diagnosis: Cholecystitis — impaction in the ductus chole-
dochus.
Operation May 22, 1893, Dr. J. B. Murphy assisted by Drs.
Lee, Hartmann and Wittwer. Cholecystenterostomy by means of
anastomosis button. The operation was performed without diffi-
culty; time, 13 minutes. A few calculi were removed at the
time of the operation.
Subsequent History. There were no unpleasant symptoms in
the subsequent course of the case; patient was discharged from
the hospital on the fourteenth day after the operation. Button
passed eighteen days after operation.
August 27, 1893. Patient has increased very much in weight,
is enjoying excellent health, attending to all her household duties,
and has had no return of the symptoms.
Case XI. Dr. A. H. Fabrique, of Wichita, Kansas, in a per-
sonal letter, under date of July 20, 1893, writes the following:
"Enclosed please find report of patient on whom I performed
cholecystenterostomy by means of your button.
32
"Mr. R , aet. thirty-eight, farmer, weight ISO pounds. Had
been subject to attacks of hepatic colic. Came under my obser-
vation about the middle of May, 1803. Had been suffering for
two weeks previous to that time with severe pain in the region
of the liver, for which he was taking one-third grain of morphine
three to six times a da}'. Jaundice all over the body for a whole
week prior to the time he consulted me.
'•Operation, June 1, 1893. Found the wall of the gall bladder so
thickened that it was difficult to fasten the button into the bladder.
I used the smallest button; duration of operation thirty-five min-
utes. Closed the opening with silk sutures through the entire
abdominal wall. Temperature did not rise any time above 99.5°F.
Union per primam. There was marked improvement on the third
day; skin commenced to clear up; no hepatic pain after the opera-
tion. Stools changed from white to a natural color; button passed
on the twenty-first day. At the present time the man is perfectly
well, pursuing his usual avocation."
Case XH. Under date of July 20, 1893, Dr. W. B. Rogers, of
Memphis, Tenn., states that immediately after his return from the
National Association of Railway Surgeons at Omaha, he had an
opportunity to use the button in the operation of cholecystenteros-
tomy.
The following is a report of the case as furnished me by Dr.
Rogers: "W. A. E , male, fifty-eight years of age. Presented
April, 1893, all the. physical signs of an enlarged liver; area of
dulness occupying the epigastrium. No bile in the stools. Icterus
marked; emaciation very pronounced; temperature 98°F.; pulse 68.
Diagnosis: 'Cancer of liver,' had been repeated by several physicians
and case pronounced hopeless. The enlargement of the liver was of
only a few months' duration. The extreme rapidity of growth aroused
suspicion of nonmalignancy. Exploratory incision revealed distend-
ed gall bladder. Eighteen ounces of mucopurulent bile; occlusion
common duct, with consequent retention and congestion of liver. No
evidence of malignant disease could be detected; nor could a cal-
culus be detected in common duct. Cause of obstruction not dis-
cerned. Patient's condition urged a rapid completion of all opera-
tive procedures, hence fistula was established. Patient recovered
from operation. Fistula discharged at least two pints of bile per
day; icterus disappeared. General condition continued bad. Ab-
sence of bile in bowel kept nutrition below par.
"Operation, June 1, 1893. I reopened abdomen and united small
intestine to gall bladder by means of Murphy's button; did not
33
attempt to close the fistula; tied thread to the button, and on the
tenth day removed the button through the fistula. No reactionary
fever nor bad symptoms other than that of depression due to
shock. Patient gradually improved, and at the end of eight
weeks was able to be up and about the house gradually gaining
strength. ' Fistula has contracted, so that dressings only need
changing every third day. Stool contains bile; appetite and diges-
tion steadily growing better, and evident gain of fiesh. I found
the application of the button quite readily accomplished; the
coaptation of parts perfect, and the results are as stated."
Case XIII. This case occurred in the practice of Dr. F. S.
Hartmann who furnished the following report : "M. McC , age
60, widow, multipara. About eight years ago she had a severe
attack of colicky pain in right hypochondriac region ; pain was
intense and lasted about three days. Patient was jaundiced during
this attack ; she does not remember any other symptoms.
"In March, 1893, she had a second attack, colicky pains
in hepatic region and epigastrium, vomiting, chills, fever, jaun-
dice ; sick about one week. Patient came from Philadelphia to
Chicago on a visit last April ; since her arrival she has had nearly
a dozen attacks of pain which would last from six to twelve hours,
and have always been followed by great prostration. The last
attack began at 1 A. M. July 13, 1893; colicky pains, great tender-
ness over upper half of abdomen, more marked in region of
gall bladder; jaundice, persistent vomiting, temperature 100°-101°F,^
bile in urine, clay colored passages.
"Operation, July 18, 1893. Cholecystenterostomy with Murphy
button, performed by Dr. F. S. Hartmann, assisted by Drs. Mur-
phy, Lee and Wittvver; time seventeen minutes. After operation
patient's condition was excellent, and her recovery was uninter-
rupted. Pulse always below 100 and good; temperature never ran
above 99.8°F., and attacks of colicky pain ceased. Vomited once or
twice daily for three days; vomited matter containing bile. Forty-
eight hours after operation gauze drain was removed from perito-
neal cavity. Bile gradually disappeared from urine, and feces
regained their color. At no time was there any great tenderness
in region of operation. Button and fourteen calculi were passed
in one stool on the fourteenth day after operation. Greatest cir-
cumference of largest calculus 2i|in; smallest circumference of
largest calculus 2\^ in; circumference of button 2i|- in. Patient
sat up on the nineteenth day after the operation.
/
/
34
• "August 29, 1893. Patient enjoying excellent health, better
than at any time since her second attack of colic."
Case XIV. In a personal letter to me, Dr. Alex. Hugh Fer-
guson, of Winnepeg, Manitoba, under date of August 14, writes the
following:
"Operation, August 3, 1893, I used your button in uniting the
gall bladder with the duodenum — cholecystoduodenostomy. Patient
passed the button on the eleventh day, and her condition is excel-
lent. The case was difficult to manipulate owing to the short
build and large amount of fat (fully three inches) in the abdominal
wall. It was a case of dropsy of the gall bladder. One stone was
removed from it, another was felt to occlude the duct."
August 28, 1893, I received a report of this case through Dr.
McArthur, of Winnepeg, who had assisted Dr. Ferguson at the
operation; he states that the patient is in excellent health, and
that Dr. Ferguson expressed himself concerning the button in the
following words: *'It is the greatest innovation in abdominal sur-
gery since that of antisepsis."
Case XV. From Dr. T. D. Lane, Media, Pa. ''Mrs. L , aet.
forty-five, married, one child. In October 1892, was taken ill with
intense abdominal pain, paroxysmal in character, accompanied by
vomiting and constipation. Jaundice appeared on second day,
also bile in urine; stools acholic; on sixth day severe chill fol-
lowed b}^ temperature of 104° F. As the jaundice was of the most
marked type, coming on suddenly with no previous history of
trouble or emaciation, vomiting or pain and the temperature and
chills persisting for several days, I sent the woman to the Jeffer-
son Hospital under the care of Prof. I. C. Wilson with the diag-
noses of acute obstructive jaundice and Charcot's hepatic fever,
with the hope that an early operation at least of an exploratory
character would be performed. She remained in the hospital nine-
teen weeks. The chills and jaundice persisted; she emaciated
rapidly; she was seen in consultation by Drs. Keen and Brinton.
Operation was deferred on account of the woman's weak condi-
tion and the possibility of malignant character of the obstruction.
The fever and jaundice finally disappeared and she was discharged
from the hospital February 1, 1893. She gained rapidly until July
15, when I was called to see her again. The vomiting, chills and
fever had suddenly returned. I determined to perform cholecys-
tostomy at once. This I was able to do without much trouble in
an operation of one sitting. I removed a verj^ large stone marked
with numerous facets. I could not discover the presence of anoth-
35
er in the common duct with my finger through the foramen of
Winslow. Supposed the obstruction was due to cicatricial contrac-
tion. Temperature dropped to normal the following day. In a
month she was up and about. Still the stools remained clay
colored and she suffered much from gaseous distention of the
bowels. She was also greatly annoyed by the voluminous dis-
charge of the bile upon the surface. I determined to close the bil-
iary fistula.
" Operation, September 20, 1893. I made a Y-shaped in-
cision over the old cicatrix, pushed the great omentum aside and
drew out a small knuckle of intestine and performed cholecystenter-
ostomy, using the smallest sized Murphy button. The fistulous
tract was curetted and closed at once with a circular stitch. The
abdominal wound was closed without drainage. The temperature
remained between 99^° and 100^° F. for several days. Otherwise
she made an uninterrupted recovery. On the fifteenth day the but-
ton was found in the stool. Since then she has been in very good
health, able to attend to all her duties and has gained twelve
pounds in weight."
Case XVI. Report of operation given by Dr. J. Frank in
whose service at St. Elizabeth's Hospital the case occurred. "Pa-
tient admitted at Hospital as a ' Perityphlitic Abscess.' Careful
examination showed that it was a very much distended gall blad-
der. An incision was made directly over the tumor. The gall
bladder was found adherent and was immediatel}^ incised; 143
stones were extracted, and the opening allowed to remain. Pa-
tient was discharged with a fistula. Returned several months
after with a large quantity of bile discharging from fistula, probed
and found stone; removed. The canal leading to bowel could not
be entered. The discharge continued in large quantity and the
patient was losing strength. It was decided to perform a
cholecystenterostomy to allow the secretion to enter the bowel in
large quantity.
"Operation Oct. 20, 1893 by Dr. M. H. Luken. An incision was
made at the side of the fistula. The gall bladder which at the time
of the first operation, was a large distended sac, had now, four
months later, contracted to a tube not much larger than a finger
and was adherent to the surrounding tissues. It was difficult to
expose a sufficient surface of the gall bladder to insert a button.
The button was finally placed in position and the duodenum united
to the gall bladder. The button passed on the 13th day without
pain. An operation has not yet been performed to close the ex-
36
ternal fistula. A patulous opening now exists between the gall
tracts and duodenum."
The difficult}^ of performing the operation of cholecystenteros-
tomy under these conditions was extremely great and as Dr. Frank
expresses it "I do not think that the operation could have been
performed by any other means than the button."
Case XVII. Dr. F. S. Hartmann furnished me with the re-
port of this case that occurred in his practice. "Patient states that
about five years ago he had an attack of painful stomach trouble; it
was not accompanied by nausea or vomiting. The illness lasted about
one week. On August 23, 1893, patient experienced a dull aching
pain in pit of stomach which lasted two days ; then suddenly be-
came much worse and of a colicky nature and was accompanied by
persistent vomiting of bile and mucus. The colicky pain lasted
two days and was very intense. The patient has had eight similar
attacks since. A characteristic feature of all his attacks has been
the peculiar manner in which three symptoms have followed each
other :
"First, acute colicky pain;
"Second, a burning sensation in chest and throat;
"Third, persistent vomiting.
"He suffered from digestive disturbances for fifteen years.
During an attack occurring September 29, a trace of bile was found
in urine. Patient was never jaundiced. No calculi were ever found
after an attack. Diagnosis, cholelithiasis, obstruction of cysticus.
"Operation October 26, 1893, by Dr. F. S. Hartmann, assisted
by Drs. Murphy, Wittwer and Lee. Cholecystenterostomy by means
of Murphy button. Gall bladder somewhat enlarged. Time for
insertion of button seven and one-half minutes. Time for entire
operation, twenty-six minutes. Convalescence uneventful. Button
passed on ninth day."
Case XVIII. W. B , aged forty years, cigar maker. Three
years ago had first typical attack of gallstone obstruction, accom-
panied by jaundice. Since that time has had five similar attacks; last
one began about two weeks ago; was less severe than previous at-
tacks.
Operation November 7, 1893, by Dr. Murphy. Cholecystenter-
ostomy by means of anastomosis button, smallest size. Gall blad-
der was found distended; gallstones not removed. Time from be-
ginning of operation to completion of anastomosis eleven minutes.
Patient acted very badly under anesthetic; ether. Had some
bronchitis following operation; aside from this his convalescence
3 7
was uneventful. Was about the ward in three weeks. Jaundice
had completely disappeared.
Case XIX. By Dr. James H. Dunn, Minneapolis, Minnesota.
" Mrs. W , age thirty seven, suffered from attacks of gall colic
every three or four months for the past four years. They were
accompanied by vomiting, jaundice, constipation, clay colored
stools. The last attack has continued for about eight weeks,
necessitating the use of large doses of morphine all the time.
"Operation January 6, 1894. Median incision, found the gall
bladder normal size, and nearly full of stones, duct impacted with
small ones. Cholecystoduodenostomy with the Murphy button;
patient's only complaint after operation was pain on deep inspira-
tion, temperature reached 100°F. once; button passed on the eigh-
teenth day, and with it twenty-six stones. Patient made an une-
ventful recovery.
"In these days it is pretty hard to say where we are in surgery
but I arfi very sure the Murphy button has come to stay."
Case XX. Case referred to me by Dr. J. H. Hoelscher, who
had made the diagnosis of cholelithiasis. Mrs. F. H , age thirty-
six; married; two children; has been sick for twelve years; has
had attacks of colic every two or three months in that time, not
always accompanied by vomiting, never by a typical jaundice
although occasionally there has been a slight icteric discoloration
of the skin, great digestive disturbance, no tumor to be felt.
Operation February 13, 1894, by Dr. J. B. Murphy. Incision
from ninth costal cartilage; gall bladder adherent to duodenum,
liberated, brought into wound, puckering string placed in position,
incised, and two stones three-fourths of an inch in diameter re-
moved, some viscid mucus but no bile escaped, button placed in
position in gall bladder and duodenum, and closed ; no drainage.
Time of operation, eleven minutes, convalescence uneventful,
patient did not even vomit from the anesthetic, and temperature
did not exceed 99°F.
VIII. Cholecystectomy, Total Extirpation of the Gall Bladder. —
This operation was introduced by Dr. Langenbuch. At first there
was most bitter opposition to the operation, but it has now obtained
great recognition. For a certain class of cases it is the operation
par excellence: 1, on account of its safety; 2, because it completely
fulfils the indications. Langenbuch is sustained in the theory of
his operations by the fact already mentioned, namely :
Absence of the gall bladder being harmless, as far as the
health of the patient is concerned, as demonstrated by the large
38
number of animals and men in which this viscus has been found to
be congenitally absent, and made no apparent difference in their
health. I have found in dogs, on which I have performed this
operation, that their health was not interfered with in the
slightest.
The onl}' question of gravit}' for the consideration of the sur-
geon, as long as its absence does not materially affect the patient^
is : What are the dangers of the operative procedure itself? That
these dangers are not great is shown by the following statistics :
We have collected in all sixty-five cases; there were eleven deaths,
a mortality of seventeen per cent, which is even more favorable
than cholecystostomy, and this operation is rapidly finding favor
with surgeons, notwithstanding the assertions of Tait when the
operation was first suggested in May, 1884, that it was "absurd;" in
June, 1885, that it was "radically absurd," and in October, 1889,
that it was "intrinsically absurd," (Courvoisier); another illustra-
tion of how valueless a man's opinion may be of an operation that
he has not tried. The indications for this operation are : 1,^
hydrops and empyema of the gall bladder when it is already dis-
connected from the choledochus by occlusion of the ductus cysti-
cus ; 2, in severe chronic recurrent cholelithiasis vesicularis ; 3, in
severe diseases of the wall of the gall bladder itself, ulceration,
gangrene, contraction and carcinoma ; 4, in internal rupture or
wounding of the gall bladder when suture is difficult or impossible.
It is contraindicated by strong adhesions to its surroundings ; by
broad and close attachments to the liver ; in all permanent
closures of the choledochus.
IX. CholedochoUthotripsy , or Crushing of Gall Stone in the
Choledochus. — The operation has been performed three times with
success, by Crede, Courvoisier and Kocher. It was found in these
cases that there were fragments after the crushing that would not
pass through the choledochus but might regurgitate back into the
gall bladder. There is also no certainty that the remainder of the
canal is patulous below the point where the fragments lodged.
Crede's patient had severe attacks of colic and fever in passing
the fragments. Again, there is danger in the act of crushing the
stones of injuring the walls of the duct so as to subsequently
cause a perforation; for these reasons this operation should not be
performed.
X. Choledocholithcctotny, with subsequent suture of duct. —
This operation has been performed five times with two deaths,
giving a mortality of forty per cent. It is a very difficult opera-
39
tion to perform as the duct is deeply seated and the escape of bile
in the field of operation after the incision is very annoying to the
operator. This operation was first performed by Courvoisier, and
he deserves great credit for his ingenuity and courage in devising
and undertaking this operation, as well as being the first to per-
form a successful cholecystendysis, and to do the first successful
choledocholithotripsy.
This operation is to be undertaken, 1, Where the stone is l^rge
and firmly impacted in the duct and when the patient has symptoms
of intermittent fever and chills. 2, Where the stone is impacted
in the duct and the ductus cysticus is obliterated, preventing the
formation of a gall bladder and intestinal fistula for the escape of
the bile. 3, Where it has produced ulcerative perforation and
the wall at the opening is in a healthy condition, otherwise the gall
duct should be excised at that point, both ends ligated and a chole-
cystenterostomy performed.
The following operation was performed:
Case I. Mrs. Matilda B , age thirty-five, multipara, ad-
mitted to hospital Sept. 20th, 1893. Enjoyed perfect health until
three years ago, at that time had first attack of colic, intense pain
of sudden origin in right hypochondriac region, very sensitive
under right costal cartilage, pain continued several hours, followed
by vomiting; was not followed by jaundice. Two years later sim-
ilar attack with no jaundice. Five weeks ago had third attack.
Has had frequent severe attacks of pain since the beginning of the
last one a week ago, which have continued to the present time,
October 20, 1893. Jaundice made its appearance for the first time
four weeks before admission, and is still present. She does not
know that she ever passed a gall stone. Never had any urinary
difficulty. Stomach always good. Was never free from tenderness
in right epigastric region since time of first attack. Present con-
dition; very icteric, rapid feeble pulse, expression of severe suf-
fering, complains of great thirst, anorexia. Very sensitive in right
hypochondriac region. No tumor perceptible. Temperature, 103°
F.; pulse, 138; respiration, 34. Diagnosis:- — Hepatic calculus im-
pacted in ductus choledochus. October 21, 8 A. M., pulse, 100;
temperature, 102.8° F.; respiration, 36; P. M. pulse, 102; tempera-
ture, 103° F.; respiration, 36. October 22, P. j\I. pulse, 96, tem-
perature 102°F. ; respiration, 40. October 23, A. M., pulse 94; tem-
perature 99°F.; respiration, 30.
Operation October 23, 11 A. M. Dr. Murph}^ assisted by
Drs. Hartmann, Wittwer, Kortebein, performed laparotom_v: found
40
gall bladder contracted to a tube, large calculus one-half inch in
diameter situated in the middle of choledochus. Gall bladder
could not be utilized for approximation to the intestine. It was
decided to remove the calculus from the common duct, which was
thoroughl}' exposed. An incision one-half inch long was made in
the duct, parallel with it, stone extracted. The opening in duct
was united with continous suture. Gauze drainage. Time forty-
five minutes. There was but very little hemorrhage during opera-
tion, and none whatever after suturing. Some shock. Pulse,
11:40 A. M., immediately after operation, 64; respiration 30; 5:30
P. M. pulse 72; temperature 9'7°F.; respiration 32; 10 P, M. pulse
18; temperature 97. 4°F. ; respiration 32.
October 24, 8 A. M., pulse 94; temperature 98.8°F.; respira-
tion 32. Rested well during night; nauseated, but no vomiting
since operation. October 24th, 6 P. M., pulse 144; temperature
103° F.; respiration 36.
October 24, 12 P. M., pulse 108; temperature 101°F; respira-
tion 26. Condition much improved; pulse still feeble.
October 25, 2 A. M., pulse 110; temperature 102° F.; respir-
ation 35. Pulse very weak. Died at 3 A. M., very suddenl)'.
Post-mortem not allowed. It is therefore impossible to say
what was the cause of death.
The clinical cases requiring surgical interference in lesions
of the gall tracts are the following :
First, in all cases of obstructive jaundice, where the jaundice
exists during a period of two weeks.
Second, in all recurrent cases of obstructive jaundice.
Third, in cases of recurrent cholecystitis.
Fourth, in recurrent cases of colic from cystic duct obstruc-
tion, alwa3's without jaundice.
Fifth, in retention cysts of gall bladder.
Sixth, in malignant growths of gall bladder.
Contraction of the gall bladder occurs in more than eight}^ per
cent of the cases of cholelithiasis. It is the result of the cicatricial
•contraction produced in the gall bladder bj' a chronic inflamma-
tion or irritation of it b}^ the gallstones; therefore the earlier the
operation is performed, the less liable we are to find contraction.
There is another danger and that a serious one; perforation of the
tracts by the calculus. I have been called in consultation within
the last eighteen months in three cases of perforation of the gall
tracts, all attended by an infective peritonitis and all died; a
histor}' of repeated attacks was given in each. In one case the
41
patient had the question of operation under advisement on account
of the frequency of attacks. None of them were suffering from
colic or obstructive jaundice at the time of the perforation, which
shows that there is danger even in the quiescent stage.
Another reason for the early operation is the danger of a
malignant growth being produced by the constant irritation.
In looking over the records of the pathological institutes we find
abundant proof that a considerable percentage of cases of chole-
lithiasis terminate with carcinoma of the gall tracts. I have seen
a large number of post-mortems presenting this condition.
These reasons, along with the dangers which accompany an
acute attack of obstructive jaundice are, I think, considering the
small percentage of mortality, sufficient to justify early operative
interference.
You will find in reviewing the results of these operations that
the mortality is greatest in the operation of cholecystenterostomy
^'in one sitting," by means of suture, in which thirty-five per
•cent of the cases terminated fatally. The operation showing the
next greatest fatality is cholecystendysis, with a mortality of
twenty-three per cent. Next high in the scale of mortality
is cholecystostomy "in one sitting," the operation which is most
prevalent and performed more frequently than any other, and
almost as frequently as all the others combined; its mortality is
nineteen per cent. This great mortality should cause every
thoughtful operator to endeavor to find some other means whereby
his patients will not be jeopardized to such a great degree, and
while the mortality is nineteen per cent, the percentage of perfect
recoveries is only about fifty-one per cent ; making the chances for
life in the ratio of five to one, and the chances for complete recov-
ery but one to two. Then comes cholecystectomy with a mor-
tality of seventeen per cent. The most favorable of the older
operations is cholecystostomy, "in two sittings," in which you
have a mortality of ten per cent.
In reference to the criticisms by Prof. Senn, Jour. Am. Med.
Ass'n., August 12, 1893, I would say that while he does not com-
ment on the use of the "button " in cholecystenterostom}', some of
his criticisms would be applicable to the use of the button in that
operation as well as operations on the intestines, therefore, I deem
it proper to treat them in this article.
First, he says that "it is no improvement on the rings
employed by Denans more than half a century ago." The cor-
42
rectness of this statement can be readih' tested by a cursory com-
parison of the two devices, (compare figure 2 and figure 6).
Second, he says " that a foreign body is left in the intestinal
canal, which may become a source of danger on its way to the
distal end of the alimentary canal." Will it become a source of
danger, and when? .The ileocecal valve is the place in the nor-
mal intestinal tract in which it would be most likely, if at all, to
produce an obstruction. That this valve in its normal condition
allows the passage of bodies much larger in diameter than the
button, is shown b}' the many experiments on that portion of the
canal. It is further shown by the clinical observation of medical
practitioners, who from time immemorial have seen children
swallow coins, nuts, peach stones, marbles and other foreign
bodies much larger in proportion to the child's intestine than
the button recommended, and pass them without producing
unpleasant symptoms. This is considered by doctors to be of so
Figure 6. — Denans' Rings.
little danger that they advise the patient "to pay no attention to
it, and forget that such a thing occurred." What surgeon would
become alarmed if one of his young patients swallowed a
coin or marble? Admit that a coin or marble, under certain
pathological conditions, has produced trouble; to the one such
case there are thousands that have not.
It will be admitted that with cicatricial contraction of the
bowel or a malformation of the ileocecal valve, obstruction might
be produced by the button, but the proportion of these cases would
be about the same as the proportion of cases of trouble produced
by the coin or marble, and so small as to be scarcely worth serious
attention.
I have now reports of three hundred (300) operations and
experiments with the button. The obstruction so much dwelt upon
by the critics of the button did not occur in one of my cases, nor
has it "come to my knowledge" that it occurred even once in the
cases of others who have performed the operation.
Dr. W. W. Keen in the same paper from which Senn quotes a
portion of a sentence referring specifically to the objection, says^
43
"on the whole, however, I do not feel that this objection is a very-
serious one, since the condition requiring the use of the buttons, if
they be used, is one which must dominate all other risks." (Anfiah
of Surgery, June, 1893, p. 660). It can therefore be seen that the
danger of obstruction by the button is so slight that it is entitled
to no weight in view of the ease with which it is inserted and the
certainty with which it fulfils its purposes.
Third. "Any instrument, suture or ligature used in effecting
the co.ntinuit}^ of a wounded or divided bowel that produces gan-
grene must be looked upon as a source of danger." The term
gangrene is misleading in this connection; the term in-
tended, no doubt, was pressure atrophy. Every suture^
every mechanical means that is used, every ligature that is tied in
approximating the intestine produces pressure atrophy in a greater
or lesser degree, or it gives no support. Shall we discard all these
useful measures? Pressure atrophy, "gangrene," (Senn) in vas-
cular tissues is limited to the area of pressure in which the cir-
culation is shut off and is always controlled thereby.
The button above all other methods, suture, rubber rings, bone
plates, etc., protects the peritoneal cavity. There is no suture on
the peritoneal surface; there is nothing left within the peritoneal
cavity; it is shut out and sealed up by a uniform compress. This
compress closes as pressure atrophy takes place and closes in the
direction of pressing the surfaces desired to be agglutinated, closer
and closer together. This is not accomplished by any other device-
True there is a substance in the caliber of the intestine, call it for-
eign if you please; so are the materials used as food to some de-
gree foreign materials, but they, like the button, are on the safe
side of the intestine within it, not without.
Fourth. " Because the lumen of the connecting part is not large
enough as a temporary outlet for the intestinal contents above the
seat of operation." This objection is not tenable. The surgeon
well informed on the physiology of the small intestine knows that
its contents are always fluid, except in cases where some indiges-
tible solid substance is introduced. Patients are not usually
allowed an ostrich diet for a few days following an intestinal an-
astomosis. No matter what medicine may be given, it does not
render the contents of the small intestine solid; they are alwa3^s
fluid. The amount of fluid that would pass through the central
opening in a medium sized button in twenty-four hours can be
easily computed, and represents man)^ times the weight of the
44
entire bod\', while the average amount of feces in the same time
is five ounces.
Fifth. The fragment of a sentence quoted b}^ Senn, from
Keen's article, is such an inadequate representation of the scien-
tific and fair manner in which this recognized authorit}^ treats
the subject, that I venture to quote more extensively from it as
follows, pages 660, 661: "The speed and certaint)^ with which
an anastomosis can be made once the bowel is prepared for it, are
certainl}' advantages which the button possesses over all other
means of anastomosis, whether by simple suturing or by bone
plates, catgut or other rings." " It is certainly a most happy
mechanical invention, especially the method of fastening it by
what is practically a secure screw, and 3'et instead of being rotated
in order to fasten it, it simpl}^ needs to be pushed home. The
two projecting teeth which answer the purpose of the male screw,
make it one of the most ingenious devices I have ever seen."
From Keen's postscript I will quote the following, as
showing the perfection of the union: "From the outside, one would
almost think that it was the normal termination of the ileum in the
colon; no more perfect union could be imagined." In regard to
the contraction found by Keen in the post-mortem which he
reports, we are compelled to admit the force of the suggestion
made to me by Dr. W. J. Mayo, that a vital point in the report of
that post-mortem is omitted, namely, a comparison of the diameter
of the ileum before operation and at the post-mortem. Before
operation there was undoubtedly, with a chronic obstruction, dis-
tention of the ileum. Did the opening contract more in propor-
tion than the ileum itself, and was not the contraction of the open-
ing due to the contraction of the ileum from its expanded, ob-
structed, preoperative condition, to itsnormal, contracted, empty con-
dition produced by a free escape at the anastomosis as found in the
post-mortem ? An analagous contraction to this is shown in cases in
which a cholecystenterostomy is performed experimental!)^; the
opening which was original!}' the size of the button used is re-
duced not by the contraction of the cicatrix, but by the contraction
of the gall bladder, which after a number of weeks is reduced to
the size of a cystic duct. Dr. C. E. Ruth, of Keokuk, in T/ie 0»ia/ia
C//;//V, September, 1893, says: "I wish to call especial attention
to the specimen in which an approximation was made between the
duodenum and the gall bladder. You see that what was a gall
bladder has ceased to exist as such, and nothing remains of it but
a duct. Its contraction has narrowed the opening which delivered
45
a five-eighth inch button until it is the size of a slate pencil and
shows well marked folds of mucous membrane at its margins that
must act as a valve to prevent the passage of intestinal contents
into the gall bladder."
A year and four months have elapsed since the first operation
of cholecystenterostomy with the button was performed upon the
human subject, and the symptoms of obstructive jaundice have
not appeared in this nor any of the subsequent cases, as was feared
by Dr. Abbe.
The following is a report by Dr. J. Henry Barbot, of San Fran-
cisco, of a case in which a post-mortem was made: {Pacific Med-
ical Jourtial, April, 1893). The operation of gastroenterostomy
was performed on December 26, 1892. The case was one of car-
cinoma, involving a large portion of the pyloric end of the
stomach. The button used was made from the description given
in my paper in The Medical Record, December 10, 1892. The patient
gained ten pounds in three weeks after the operation. She-
became so indifferent about her food that she ate beefsteak, pota-
toes, fish, fried tripe, bananas and other food difficult of digestion.
These were all eaten before the button was voided, and still there
was no obstruction. She died February 10, forty-six days after
operation, of an acute pulmonary infection. The following is the
doctor's report of post-mortem: 'T examined the stomach and
found the opening into the bowel large enough to almost admit two
fingers, and the union absolutely perfect." You will note that the
length of time that had elapsed between the time of operation and
death was only one day less than in Keen's case, still the opening
remained almost large enough to admit two fingers.
Dr. C. E. Ruth, Omaha Medical Clinic, September, 1893, com-
ments as follows: "This not only simplifies, but gives an element
of certainty in this formerly impracticable operation, that is
scarcely believed until seen. Its importance can scarcely be over-
estimated. The operation has been done successful!)' on eight
persons. You will notice that no such contraction occurred in any
of the specimens as that which occurred between the gall bladder
and duodenum; in fact none whatever. I have done gastroduo-
denostomy, cholecystenterostomy, lateral and end to end approx-
imations, specimens from all of which I now show you, and in no
case did I fail to get firm union without a fistula or a particle of
fecal or gaseous extravasation."
Dr. F. Andrews, of Chicago, in Omaha Clinic, September, 1893,
says: "It is the means par excellence for establishing a gastric or
46
fecal fistula. B}' having a string attached, as soon as pressure
atrophy h,as released the button, it is at once drawn out of the
wound, without being allowed to pass through the intestinal tract."
Dr. McFadden Gaston, referring to the button, in Southern
Medical Recorder, ]n\y, 1893, writes: "This device * * * for uniting
different structures has now been tested in a sufficient number of
cases to afford a reasonable reliance upon its efficacy. The results
were entirely satisfactory in the demonstration of the adaptation
of the button for anastomosis, and there can remain but little
doubt of a communication with surrounding adhesion being ac-
complished by it, with more expedition than by processes heretofore
adopted."
Dr. Hugh Ferguson, Winnepeg, used the button for a case of
pylorectomy with end approximation of duodenum to side of
stomach, also in a case of cholecystenterostomy, both successful.
In a personal letter he writes as follows: "I am more than pleased
with the anastomosis button. It is really more than an anastomo-
sis button and should be designated 'Murphy's Intestinal Button.'
If a discussion on the button arises at the Pan-American Meeting
you may quote these two cases. The button cannot be too soon
known."
Dr. W. B. Rogers, Memphis, Tenn., July 30, 1893, writes : "I
would say that immediately on my return here I had an opportunity
for using your button for the operation of cholecystenterostomy
and it worked like a charm."
Dr. R. F. Weir, of New York, writes: "I have used the 'button'
for cholecystenterostomy and like its ease of application, though
the fatal ending prevented the fullest test being made. The result
however was not due to the method but to the case itself, which
was neoplasm compressing common duct and engaging both liver
and pancreas."
Dr. J. Henry Barbot, {Pacific Medical Journal, April, 1893),
who used the button in performing a gastroenterostomy, com-
ments as follows: "An anastomosis ma}^ be done by this method
with perfect safety and with a result that cannot be obtained by
any other method. The day of bone plates, catgut rings and nu-
merous other devices, that have been used in performing the anas-
tomosis operations, is past and every surgeon should provide him-
self with a set of the buttons which does not require an extensive
amount of operative skill to use."
In a recent communication Dr. Willy Meyer, of New York,
favored me with a report of two successful operations with the
47
anastomosis button and commented as follows: "In both cases
your button worked like a charm, impressing me and everybody
present, that, in your ingenious device, we have entered a new era
of modern intestinal and gall bladder surgery."
LITERATURE.
M. A. Le Dentu, Deux cas de cholecystectomie pour lithiase, un cas-
d'ict^re chronique cause par un cancer primitif du pancreas, non opere. Bull.
Acad, de Med. Dec. 30, '90, p. 863.
Rafin. Phlegmon de la vesiculebiliaire; incision; e.Ktraction decalculs; gueri-
son. Lyon Medicate, No. 18, 3 Mai. 1891.
M. F. Terrier. Cholecystectomie. Bull, de I'Acad. de Med. 10 Mars
1891.
Thomas J. Mays. Sweet oil in treatment of gallstones. Buffalo Med. Jour-
nal, Nov. 1891, p. 207.
James Bell. On a fatal case of acute peritonitis. Montreal Med. Journal,
Vol. XXI., No. 2.
John Thomson. On congenital obliteration of bile ducts. Read before Edin-
burgh Obstet. Society, 1891.
D. N. Morrison. Biliary Calculi. Maritime Med. A^ews, Sept. 1892, p. 164.
S. R.Morrow. Discussion on treatment of gallstones. Albany Med. Annals,
Vol. XIII., No. 9.
T. A. Pope. Black Jaundice. Courier-Record of Medicine, Texas, April,
1892.
S. Eastmann. Clinical contribution to the surgery of the gall bladder. Cin-
cinnati, Dec, 1891.
S. M. Ward. Acute infectious jaundice. Aled. and Surg. Reporter, Vol. XV.,
p. 490.
H. F. Main. A case of cholelithiasis. Australian Med. Journal, Vol. XII.,
No. 11.
M. Terrier. Ponction et resection de la vesicule biliare. Bull, de I'Acad. de
Med., Dec. 23, 1890, p. 831.
E. Willemin. Med. a Vichy. Traitement de coliques hepatiques par I'huile
d'olive.
Girode. Quelques faits d'ictere infectieux. Arch. Gen. de. Med., Feb. 1891.
Terrier. Archives Gen. de Med., February 1891.
Terrier. Observations de cholecystotomie et de cholecystectomie. Bull, de
I'Acad. de Med., June 16, 1891.
Seymour. Case of cholecystotomy. A/nerican Med. Journal, 1892, Jan. 23,
p. 95.
Stein. Cholecystotomy. Cincinnati Lancet-Clinic, Aug. 15, 1891. p. 201.
Mayo Robson. Cholecystotomy for gallstones. The Lancet, Jan. 10, 1891, p. 79.
Reeve. Some surgery of liver and gall bladder. N'. Y. Med. Jour?ial, May
28, 1892.
Lange. Extirpation of gall bladder. yV. Y. Med. Journal, Jan 17, 1891.
48
Dawson. Successful cholecystectomy. Med. Ncuis, Dec. 6, 1890, p. 597.
Hamaker. A case of cholecystotomy. International Journal of Stirgery^'^z.y,
1891.
W. J. Mayo. Report of tv\o operations for gallstones. N'orthtuestern Lancet,
April 1892.
Walker. Removal of gallstones by ether solution. Lancet, April, 1891.
Murphy. Cholecystotomy. British Med. Journal, Jan. 24, 1891.
Easterly Ashton. A case of cholecystotomy for removal of gallstones.
Therap. Gazette, May, 1893.
Morse. Cholecystotomy. Occidental Med. Times, Vol. V., No. 6.
Perkins. Case of impacted gallstones with abscess formation. Kansas City
Med. Index, Vol. XII., No. 138,
Seymour. Personal experience with gallstones and operation for their relief.
Medical Record, December 6, 1890.
Galatz. Lithisia biliara. Clinica, November 15, 1891.
Grundzach. Ueber Gallensteine im Magen. Wiener Med. Presse, 1891, No. 28.
Kahler. Ueber Cholelithiasis. Internationale klifiiscke Rundschau, Novem-
ber 16, 1890.
Pfuhl. Zur Geschichte der weilschen Krankheit. Berliner med. Wochen-
schrift, 1891, No. 50, p. 1,178.
Rosenberg. Ueber die Methodik der Untersuchung auf cholagoge Sub-
stanzen und ueber deren Wirkung bei katarrhalischem Icterus und der Gallen-
steinkrankheit. Berlin, klinische Wochenschrift, 1891, No. 34, p. 842.
Schmitz. Intermittierende Fieber bei Gallensteinen. Berlin klinische Woch-
enschrift, 1891, September.
Rheinstein. Die Palpation der Gallenblase. Berliner klinische Wochenschrift,
December, 1891, p. 1,211-.
Sacharyin. Anwendung des Calomel bei Erkrankungen der Gallenwege. Ber-
liner klinische Wochenschrift, June 22, 1891.
Abbe. A large gallstone producing complete intestinal obstruction. N. Y.
Med. Journal, May 2, 1891.
Syers. Jaundice in children. The Lancet, September 12, 1891.
Sydney Jones. Perforation of gall bladder. British Med. Journal, April 25,
1891.
Seymour. Treatment of gallstones. Ainer. Med. Journal, April 25, 1891.
Goodhart. Remarks on gallstones. British Med. Journal, January 30, 1892.
Arbuthnot Lane. Rupture of gall bladder. The Lancet, May, 1891.
Wagoner. Gall bladder containing forty stones. N. Y. Med. Journal,
August, 1891.
Richardson. Removal of gallstones. Boston Medical and Surgical Journal,
January to April, 1892.
Morton. Obstruction and inflammation of gall bladder. American Practi-
tioner and Neivs, Vol. X., No. 12.
Meachem. Gallstones discharged through an abscess. Med. Standard,
August, 1891.
McCasey. Cyst of peritoneum, resulting from impacted gallstones. Kan-
sas Med. Journal, January, 1892.
Martin. Cholecystotomy. British Med. Jotirttal, January, 1893.
Veer. Two cases of cholecystotomy. Medical Record, Vol. 40, No. 22.
Adams. A case of biliary calculus. Boston Medical and Surgical Journal,
Vol. CXXVI., No. 3.
Macdonald. A case of cholecystotomy. Northwestern Lancet, July 1.5,
1891.
Abbe. Cases of gall bladder surgery. N. V. Med. Journal, January 1892.
Marcy. Surgical relief of biliary obstruction. Jnl. American Med. Assn.,
December, 1890.
Maurice Richardson. Gall bladder surgery. Boston Med. a7id Surg. Jour-
nal, Vol. CXXVI., No 17.
Cabot. Two cases of cholecystotomy. Boston Med. and Surg. Journal, Vol.
CXXVI., No. 17.
Mixter. Retention cyst of gall bladder. Boston Med. and Surg. Journal,
Vol. CXXVI., No. 17.
Gay. Cases of cholecystotomy. Boston Med. and Surg. Journal, Vol.
CXXVI., No. 17,
L. G. Courvoisier. Pathologic und Chirurgie der Gallenwege, Leipzig, 1890.
V. Winiwarter. Prager med. Wochenschrift, 1892, No. 21, 22.
Kappeler. Corrbl. fur Schweizer Aerzte, 1887, No. 17 and 1889, No. 4.
Dastre. Corrbl. fur . Schweizer Aerzte, 1889, No. 20.
Monastyrski. Chirurg. Westtiick, 1888, May and June refer. Ctrbl. fur Chir.
1888.
- Socin F. Ber. d. chir. Abthl. d. Easier Spitals, 1887, pp. 60, 61.
Fritsche und Blattmann. Corrbl. f. Schweizer Aerzte, No. 6, 1890.
Mayo Robson. Brit. Med. Jotirnal, Nov., 1889.
Terrier. Revue de. Chirurg. 1889, No. 12.
Bardenheuer. Tageblatt d. 6i Vsmmlg. Deutscher Nattirforscher und Aerzte, in
Koln; Berlin, klin. Wochenschrift, 1888, October 22 and Centralbl. fur Chir., 1889,
No. 12.
Czerny. Deutchemed. Wochenschrift, 1892, No. 23, p. 516.
Lambotte. La Presse Medicate Beige, July 3, 1892.
Connell. New York Med. Record, September, 1892.
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Brit. Med. Journal, May 18, 1889.
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Landois and Sterling. Physiologie, 1890.
50
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